key: cord-314720-pzq9muce authors: kaliya-perumal, arun-kumar; omar, usama farghaly; kharlukhi, jacquilyne title: healthcare virtualization amid covid-19 pandemic: an emerging new normal date: 2020-06-12 journal: medical education online doi: 10.1080/10872981.2020.1780058 sha: doc_id: 314720 cord_uid: pzq9muce nan the covid-19 pandemic has impacted us at various levels. currently, we cannot predict how long this pandemic is going to last nor if there will be a second wave. hence, it is necessary that we stay diligent on the safe distancing policy that is in practice in most institutions. in line with this policy, hospitals need to restrict patient numbers both in the outpatient clinics and inpatient wards. for this reason, hospitals are now encouraging virtual healthcare wherever possible, shedding the earlier hesitation to adopt the same [1, 2] . virtual healthcare is a common term for the various digital healthcare modalities that patients can use to seek medical advice. this not only includes the telehealth platforms (video, audio and instant messaging) that healthcare providers can use to remotely communicate with patients but also all other validated digital services for patient education and mentoring. even though virtual healthcare was in practice before the pandemic, it was not in the limelight. only radiologists and pathologists routinely reported from a distance, whereas others used telehealth platforms for follow-up and education of pre-diagnosed patients with a common chronic condition or for postprocedural monitoring that doesn't require eliciting of signs. it was thought to be not suitable for first visits since a comprehensive physical examination cannot be performed. now that patient visits to hospitals must be restricted due to the pandemic situation, patients have started to adopt virtual healthcare technologies, especially telehealth platforms as a first line option to seek clinical care and healthcare providers are using this to perform a virtual triage using dialogue and questionnaires to shortlist who needs to be examined in person. since most institutions are having a first-hand experience of how virtual healthcare works, we may move to a future with virtual healthcare as an integral part of health care infrastructure. however, since we do not know how this new normal is accountable medicolegally, healthcare providers need to act wisely in selecting patients for virtual healthcare. health care providers need to be familiar with the technology and receive orientation prior to adopting telehealth platforms; in addition, 'health professionals have to comply with existing legislation, associated regulations, and the medical ethical guidelines adopted and followed in their country' [3] . on the other hand, patients opting for virtual healthcare, especially for telehealth consultations need to be educated and reliable, as the information they provide is vital for making decisions. they should be aware that any misinformation or missed information could compromise their health and should understand the limitations of virtual healthcare and provide appropriate consent. given the digital nature of virtual healthcare, there is also a threat to data confidentiality and security and this needs to be overcome. even though there are concerns regarding virtual healthcare, there are many advantages, including, but not limited to convenience, cost-effectiveness, timeliness of care and specialist access to people in remote areas [4] . these advantages outweigh the concerns. with more and more institutions adopting virtual healthcare, it is impending to become the new normal after this pandemic palliates [5] . this is something that this pandemic situation has made us effectuate after so many years of living with the required technology but being uncertain of its potential. it is time to overcome the challenges and be prepared for the virtual healthcare revolution. virtual health care in the era of covid-19 telemedicine in the era of covid-19 medicolegal, ethical, and regulatory guidelines pertaining to telehealth virtual online consultations: advantages and limitations (vocal) study telehealth transformation: covid-19 and the rise of virtual care the authors declare no potential conflict of interest. no funding was received in support of this work. key: cord-031975-no3dawlg authors: nan title: editorial perspective september 2020 jvn issue date: 2020-09-16 journal: j vasc nurs doi: 10.1016/j.jvn.2020.08.001 sha: doc_id: 31975 cord_uid: no3dawlg nan editor's perspective editorial perspective september 2020 jvn issue several months into the pandemic, we have gained a better understanding of covid-19. access to healthcare remains challenging for patients and their families. as we propel toward virtual visits with great successes, such as managing chronic diseases, there are concerns for provider shortages. practicing across state lines is complicated as providers attempt licensing in other states. compact licensing alleviates the shortage, however this has not proven beneficial for providers such as mds, advanced practice registered nurses (aprn), and physician assistants. as we continue navigating uncharted territory coupled with healthcare provider shortages, the usage of chatbots has surged. chatbots is software that allows the user to simulate real conversation between devices and user via conversational interfaces (ci). 1 most corporate companies currently utilize chatbot such as banking, hospitality, and e-commerce to name a few. the transition of chatbot use in healthcare is a newer concept. in attempts to provide efficient and effective access to healthcare, ''doctorbot'' streamlines access to health information through a series of interactive conversations simulating human interaction. 2 the use of artificial intelligence (ai) has revolutionized healthcare with the ability to analyze data and leverage learned information geared toward a more proactive healthcare model. 3 doctorbot is a health assistant ci collecting healthcare information, evaluating personal health information, and providing recommendation on health-care including scheduling an office follow up appointment. ai has dramatically changed healthcare. imagine a patient has been discharged from the hospital after a vascular procedure; they are home and have questions. doctorbot can assist the patient by understanding and assessing questions and if indicated schedule a follow up appointment with the healthcare provider to address any continued concerns based on the patient response. the utilization of doctorbot can potentially reduce healthcare expenses. since this is a fairly new concept in healthcare, continuous data collection, and data analysis overtime will provide information to improve, revise, and tailor to the needs of our patients. virtual visits coupled with doctorbot provide assistance to patients around the clock at their fingertips. this combination can potentially reduce emergency room visits and move patient care to the outpatient setting, which is more cost effective than an inpatient hospitalization. jasmiry bennett, dnp, rn, acnp-bc editor-in-chief communicability of traditional interfaces vs chatbots in healthcare and smart home domains proceedings of the 6 th international conference on multidisciplinary approaches doctor bot: how artificial intelligence is already changing healthcare, and what's coming next key: cord-283413-xapzer5s authors: chan, a. k. m.; nickson, c. p.; rudolph, j. w.; lee, a.; joynt, g. m. title: social media for rapid knowledge dissemination: early experience from the covid‐19 pandemic date: 2020-03-31 journal: anaesthesia doi: 10.1111/anae.15057 sha: doc_id: 283413 cord_uid: xapzer5s the current covid-19 pandemic is threatening global health. rates of infection outside of china are rapidly increasing, with confirmed cases reported in over 160 countries as of 19 march 2020 [1]. during the severe acute respiratory syndrome (sars) epidemic, 21% of the global cumulative case total were healthcare workers [2], while a recent study from wuhan, china reported that 1716 healthcare workers were infected with covid-19, representing 3.8% of confirmed cases [3]. during the sars epidemic, it is likely that a lack of awareness and preparedness put healthcare workers at risk [4]. thus, delivering rapid, reliable information that addresses critical infection control issues is of key importance, and tracheal intubation is known to be associated with a high-risk of transmission of viral infections to healthcare workers [5, 6]. the current covid-19 pandemic is threatening global health. rates of infection outside of china are rapidly increasing, with confirmed cases reported in over 160 countries as of 19 march 2020 [1] . during the severe acute respiratory syndrome (sars) epidemic, 21% of the global cumulative case total were healthcare workers [2] . however, a recent study from wuhan, china reported that 1716 healthcare workers were infected with covid-19, representing 3.8% of confirmed cases [3] . during the sars epidemic, it is likely that a lack of awareness and preparedness put healthcare workers at risk [4] . thus, delivering rapid, reliable information that addresses critical infection control issues is of key importance, and tracheal intubation is known to be associated with a high risk of transmission of viral infections to healthcare workers [5, 6] . the challenge is how to transfer knowledge of current best practices to the people who need it most, at a pace equal to or better than the spreading epidemic. the paths for, and rate of dissemination of traditional scholarly publications [7] , static websites and even email are known to be slow. during the sars epidemic, worldwide internet access was well established, yet gaining access to potential medical users was largely reliant on email contact and personal communication [8] . preventing infection and promoting psychological wellbeing to front-line healthcare workers during an epidemic is essential and the negative psychological impact of sars on healthcare workers was exacerbated by uncertainty and unfamiliarity with infection control measures [4] . infection of healthcare workers disproportionately increases work-load and reduces the capacity of staff and hospitals to continue to provide patient care [10] . well-designed infographics have the potential to provide concise and practical information to institutions and healthcare workers and are associated with higher reader preference and lower cognitive load [11, 12] . they aid knowledge translation by increasing information retention according to the cognitive load theory and dual coding theory [11] . moreover, making infographics easily accessible, engaging, reusable and modifiable to fit local needs and user requirements is more likely to meet the imperatives of diffusion of innovation to combat the current pandemic [13] . there are limitations to dissemination of online resources, and before considering implementation, healthcare workers must critically appraise the information provided [14] . known risks of non-peer-reviewed materials disseminated via social medial include the application of context-specific resources to unsuitable situations; engagement with biased knowledge within echo chambers' (groups consisting of only like-minded individuals) and algorithm-driven filter bubbles that selectively display information based on user preferences [15] ; and insufficient source information available to box 1 criteria for the responsible use of social media disseminated information. 1 preferential use of established professional forums, or communication groups to deliver information. 2 clear identification of the information sourceallows user to judge the likely veracity and quality of information. 3 declaration of conflicts of interest, when appropriate. 4 identify methods to verify the source when appropriate or necessarywebsite address if source not readily accessible by simple search strategies, or institutional email address of originator. 5 transparent methods for peer review and feedback, for example, utilising transparent foam platforms for postpublication peer review processes, provision of author/institutional contact details so that criticisms can be directed directly to originators. 6 transparently acknowledge and document collaborations with identified professional experts, and when necessary adjust information to meet contextual needs. 7 pursue a traditional peer review process as soon as feasible and, if appropriate, reference peer review results once obtained. distinguish between valid and invalid information [16] . in medicine, there is the additional risk of early adoption of unvalidated research or practice, and the risk of future medical reversal [17] . some of these issues are not unique to non-peer-reviewed resources, and peer-reviewed materials face similar challenges [18] . to address these limitations, we propose criteria to be implemented by users of professional social medial platforms to promote the responsible use of social mediadisseminated information (box 1). in the current covid-19 pandemic, social media has the potential, if responsibly and appropriately used, to provide rapid and effective dissemination routes for key information. the example provided validates this possibility. in summary, the infographic presented met the majority of above proposed criteria. the success of the dissemination was, we believe, promoted by the existing reputation of the institution, quality of the infographic imagery and content and the rapid dissemination by social media platforms with professional participants. this allowed several institutions to utilise the time-consuming work already done in the original institution, and not have to repeat the investment of time and energy to reproduce similar material. free and rapid access to high-quality information from verifiable sources is valuable to optimise the global medical response to crises such as the current covid-19 pandemic. covid-19): situation report -59 world health organization. summary of probable sars cases with onset of illness from 1 characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention severe acute respiratory syndrome (sars) and healthcare workers transmission of severe acute respiratory syndrome during intubation and mechanical ventilation aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review getting the word out: new approaches for disseminating public health science sars and the modern day pony express (the world wide web) from smartphone to bed-side: exploring the use of social media to disseminate recommendations from the national tracheostomy safety project to front-line clinical staff report of the select committee to inquire into the handling of the severe acute respiratory syndrome outbreak by the government and the hospital authority exploring the role of infographics for summarizing medical literature the impact of social media promotion with infographics and podcasts on research dissemination and readership diffusion of innovations free open-access medical education (foam) and critical care the filter bubble: how the new personalized web is changing what we read and how we think dissemination of medical publications on social media -is it the new standard? can social media bridge the gap between research and practice? data fabrication and other reasons for non-random sampling in 5087 randomised, controlled trials in anaesthetic and general medical journals key: cord-305104-jk6ai1od authors: escribese, maría m; nistal‐villan, estanislao; fernandez, paloma; rico, pilar; martin‐antoniano, isabel a; de la cuerda, alicia; chivato, tomas; barber, domingo title: cross‐sectional pilot study exploring the feasibility of a rapid sars‐cov‐2 immunization test in health and non‐healthcare workers date: 2020-08-05 journal: allergy doi: 10.1111/all.14545 sha: doc_id: 305104 cord_uid: jk6ai1od nan this article is protected by copyright. all rights reserved cross-sectional pilot study exploring the feasibility of a rapid sars-cov-2 immunization test in healthcare and non-healthcare workers to the editor: coronaviruses (cov) are large, enveloped, positive-strand rna viruses and until the first outbreak of sars in 2002 had long been considered pathogens with low hospitalization incidence for healthy people. sars-cov-2 is a novel pathogenic cov responsible for a new type of pneumonia. initial reports placed the initial outbreak in wuhan (china) in december 2019, and it has since spread and caused hundreds of thousands of deaths worldwide (1) . the virus pandemic has spread extremely fast and it is reasonable to suggest that further outbreaks may appear along the next years before effective treatments or vaccines are available in the market (2) . thus, in the meantime, only by achieving a better diagnostic monitoring and by understanding the interactions between the virus and host immune response will we be able to rationally manage future outbreaks. the immune response to sars-cov-2 is currently under study and needs to be better characterized. however, it has been previously reported that viral infection involves activation of cd8+ cytotoxic cells, antibody-producing b cells, and innate immune response that in some patients triggers a so called "cytokine storm" (3) . moreover, whether immune responses to sars-cov-2 generate long-term memory or whether immunized patients have long-term sterilizing immunity is still unknown. spain has been devastated by the covid-19 pandemic with more than 280.000 confirmed cases, from which more than 67.000 were in madrid, causing a huge personal, health system and economic burden (4) . in fact, more than 20% of infected subjects were healthcare workers (4). we aimed to generate an immune response map to sars-cov-2 in a very specific population of a medical school were both healthcare workers and non-healthcare workers cohabit, and elucidate the main risk factors that can be associated with covid-19 diagnosis in each population. with that purpose, we analyzed a population of 100 people mainly ascribed to the medical school of san pablo ceu university and one of its university hospitals, hm monteprincipe (hmm), where students perform the last four years of the medical degree. the population of study included 50 medical doctors from hmm that were exposed to viral loads on a daily basis (healthcare workers) and 50 researchers and teachers from the medical school that can be considered as a representative sample of the general population (nonhealthcare workers). in this study we used the so-called "fast" igm/igg immunological commercial kits this article is protected by copyright. all rights reserved (real 2019-ncov rapid test cassette) to analyze the population immunity. healthcare workers were recruited and classified in two subgroups depending on whether they were diagnosed or not for covid-19 by rt-pcr. table 1 shows that healthcare workers with a confirmed diagnosis by rt-pcr display a significant association with symptoms such as fever, cough, fatigue, dysgeusia and anosmia. moreover, diarrhea, even if it does not show a significant association, presents an or of 2.65, suggesting this symptom as a novel risk factor associated with covid-19 diagnosis. moreover, the immunological tests demonstrate that almost 96% of the subjects diagnosed by rt-pcr were positive for igg with an or of 42.2. thus, it seems there is a clear association between symptoms, rt-pcr results and the positive results for igg test. moreover, in the non-healthcare workers population, no rt-pcr were performed for diagnosis and only 7 out of 50 subjects (14%) in the group were positive for igg. interestingly, these results agree with those recently published by the spanish ministry of health regarding a seroprevalence study in spanish population (n= 60.000 citizens) with different range of age, region, economic income, ect. the epidemiological study shows a seroprevalence of 11% in madrid. furthermore, table 2 shows that in this group, positive igg subjects present a significant association with fatigue, dysgeusia and anosmia. surprisingly, no association was found with symptoms such as fever or cough. a possible explanation for these results might be that healthcare workers were exposed to higher viral loads and during more time along the peak of the pandemic, while non-healthcare workers were confined at home. in fact, almost all of them presented the above-mentioned symptoms during the first 2 weeks of lockdown. igm results were not conclusive in either group. this pilot study is the first step in the elucidation of a "population immunological map" in our special community in the medical school with healthcare and non-healthcare workers. the results demonstrate that the prevalence of covid-19 is higher in healthcare workers, as expected. additionally, this pilot study provides the knowledge and the positive controls (healthcare workers with positive rt-pcr) for the development of future methodological strategies aiming to set up new immunological tests for herd immunity follow-up (elisa, neutralization assays, etc.).this will be helpful if we take into account the shortage of commercial kits for sars-cov-2 immunological tests during the pandemic, and the limitations of these tests in terms of specificity and sensitivity (5, 6)(). additionally, the results obtained from this rationale together with the information related to previous this article is protected by copyright. all rights reserved pathologies and risk factors will allow the design of personalized strategies of reincorporation into academic activities in the future. this will significantly reduce the human and economic burden of future covid-19 infection waves in our community. the proposed strategy can be easily implemented by several research laboratories and might help in better activity plans in other locations to be ready for future outbreaks. coronavirus infections-more than just the common cold projecting the transmission dynamics of sars-cov-2 through the postpandemic period immune response to sars-cov-2 and mechanisms of immunopathological changes in covid-19 distribución geográfica de los casos totales y los casos de las últimas 24h (obtenidos a partir de la declaración agregada de casos del ministerio de sanidad) development and clinical application of a rapid igm-igg combined antibody test for sars-cov-2 infection diagnosis serology assays to manage covid-19 we would like to thank francisco rodriguez, phd, ramses reina, phd and luis martinez gil, phd for kindly providing essential molecular tools (full length spike protein and vlp reporters for neutralization assay and vlps for elisa) to perform the planned assays.we acknowledge the collaboration of all the participants in the study as well as nurses in the oncology department at hmm. we would like to thank tomás clive barker tejeda for his help revising the manuscript dr. escribese has nothing to disclose. dr. nistal villan has nothing to disclose. dr. fernandez martinez has nothing to disclose dr. rico has nothing to disclose. dr. martín antoniano has nothing to disclose. dr. de la cuerda has nothing to disclose. dr. chivato has nothing to disclose.dr. barber has nothing to disclose. the authors declare that they do not have any conflict of interest in relation to this study. pf and pr collected patients' information and performed immunological tests. ac participated in patient information collection and immunological test performance at hm monteprincipe, iama performed the statistical analysis and mme, env, tc and db analysed and discussed the results and wrote the manuscript. key: cord-344435-rweyarop authors: rodriguez‐wallberg, kenny a.; wikander, ida title: a global recommendation for restrictive provision of fertility treatments during the covid‐19 pandemic date: 2020-04-08 journal: acta obstet gynecol scand doi: 10.1111/aogs.13851 sha: doc_id: 344435 cord_uid: rweyarop nan at this moment, the healthcare services of many countries are becoming overloaded, and several countries have also implemented laws to limit people's movements as well as enforcing quarantines. healthcare personnel are being reallocated to be able to provide healthcare for individuals affected by the pandemic. we are in an emergency situation that is new for us and that is obviously not a safe situation. we hope that the temporarily suspended fertility treatments can be resumed shortly and will be performed under safe conditions in the best interests of our patients who are dealing with infertility. eshre statement on pregnancy and conception novel corona virus disease (covid-19) in pregnancy: what clinical recommendations to follow? society for assisted reproduction. a special message to sart members updated statement of the covid-19 fsa response committee key: cord-271582-xo2a4wnj authors: chew, christopher; ko, danielle title: medical ethics in the era of covid‐19: now and the future date: 2020-08-05 journal: respirology doi: 10.1111/resp.13927 sha: doc_id: 271582 cord_uid: xo2a4wnj nan coronavirus disease 2019 (covid-19) should not have caught us so unprepared. for decades, public health organizations and experts urged better preparation for an inevitable zoonotic pandemic. instead, as the pandemic ravaged developed nations in the early months of the pandemic, covid-19 exposed conflicted political leadership, limited vital medical supplies including personal protective equipment (ppe) and under-funded public health system capacity. europe, the united kingdom and the united states-despite their wealth and well-resourced healthcare systems-all experienced social and economic disruption without peacetime precedent. similarly, covid-19 has forced healthcare workers in developed countries to confront moral dilemmas that have received limited attention from policymakers, clinicians and ethicists until now, but are part of daily life for their counterparts in resource-poor nations. at the time of writing, over a hundred articles on covid-19 clinical ethics have been published-a testament to one of the most clinically, personally and ethically challenging experiences in living memory. nevertheless, few have broached truly new or unexpected ethical ground. take the early debate on how to allocate life-saving ventilators. as italy became the first major outbreak outside china in march, their peak society for anaesthetics and critical care issued a then-divisive guideline about the allocation of intensive care resources. 1 particularly contentious were suggestions of an upper age limit for ventilator eligibility, the implicit condoning of ventilator withdrawal if necessary and an explicitly utilitarian focus on maximizing clinical outcomes. yet for all the controversy, the guideline mostly drew on longstanding and arguably well-accepted ideas in the allocation of scarce healthcare resources-the 'fair innings' argument; the ethical equivalence of withholding and withdrawing medical interventions; and the use of quality-adjusted life years and cost-benefit analyses numerous authors have also previously argued for similar principles in the ethical allocation of ventilators in a pandemic. 2 many other ethical discussions highlighted by the early months of covid-19 are likewise issues that have been overlooked for too long. public health ethics has seen renewed relevance, including highly charged debates about the provision of ppe and whether healthcare workers have a 'duty to treat'. 3 the ethics of clinical research and the use of experimental treatments in the face of emergent diseases has also been re-energized, 4 after interest following the 2013-2016 ebola epidemic waned. as we move forward into the long 'dance' with covid-19 ahead, we must instead seek to pre-empt and promote robust discussion of the ethical challenges awaiting us. attempts to develop effective treatments and vaccines are underway but likely remain some ways off. even so, significant disagreement has already arisen about how we should fairly distribute the limited supplies obtained from this scientific endeavour. 5 in the meantime, second waves have stunted attempts to re-open economies and healthcare systems, even in countries lauded for their strict initial public health response. despite this, the escalating consequences for financial and mental health from repeated population-wide lockdowns raise difficult questions about ethical trade-offs against reducing the harm and spread of covid-19. one struggle emerging at the clinical coalface is preserving the vital relationship between patients and healthcare providers despite unprecedented change in medical systems and delivery of care. hospitals have cancelled elective surgeries to conserve vital ppe supplies, beds and manpower. access to intensive care level (icu)-level care has been restricted. face-to-face outpatient clinics have been abruptly shifted to consultation by phone or digital screen. and more pervasively, stringent infection prevention controls have drastically altered the patient experience and quality of care. many inpatients face prolonged precautionary isolation without the reprieve of visits from friends and family, attended by anonymous caregivers in protective gear. indeed, no stories have been more emotionally moving than that of families denied access to dying loved ones spending their last hours in isolation. that these changes have largely been accepted by the public is testament to both the extraordinary fear surrounding covid-19 and the renewed global respect for 'healthcare heroes'. but, we should not presume that this goodwill is endless or indefinite. in the united kingdom, for instance, clumsy attempts to fill do-notresuscitate orders by mail with aged care residents have drawn community ire, 6 as have hasty guidelines suggesting blanket bans on cardiopulmonary resuscitation. 7 the burden of diseases other than covid-19 has not changed, and we must find ways to continue to deliver necessary care. unless we continue to act with compassion and transparency, particularly towards our most vulnerable patients and at the end of life, we risk jeopardizing the vital trust of the communities we serve. finally, as cases of covid-19 continue to rise in developing countries, our early experiences must also serve as a stark reminder of the global healthcare inequities that still exist today. those of us in developed nations have been scarred by our encounter with the spectre of contagious infections, the grim choices necessitated by resource scarcity and sudden socioeconomic fragility. yet these are day-to-day realities in poorer countries, and in even disadvantaged subgroups within developed nations. even as we struggle with covid-19 in our own neighbourhoods, we must find ways to correct these global issues. without concerted action from governments, healthcare workers and civil society worldwide, these vulnerable populations will both endure disproportionate suffering from covid-19 and serve as potent reservoirs for ongoing spread. if anything, the covid-19 pandemic must remind us once again that medicine is both 'science' and 'art'. it is not breakthrough scientific discoveries that have been most consequential thus far, but rather arduous deliberations and action on emerging ethical issues. even as the scientific community frantically works towards a vaccine, it remains critical that clinicians, ethicists and the community come together to grapple with the ethical quandaries we face in a transparent, fair and inclusive manner. if we do not maintain the trust of our patients and communities; guard our healthcare workers against moral distress and burnout; and begin to correct the gaping health disparities that currently exist, we cannot truly be rid of covid-19. most crucially, how we act now will not just determine the future course of the pandemic-it will shape the nature of the society that emerges on the other side. clinical ethics recommend ations for the allocation of intensive care treatments in exceptional, resource-limited circumstances: the italian perspective during the covid-19 epidemic who should receive life support during a public health emergency? using ethical principles to improve allocation decisions what healthcare professionals owe us: why their duty to treat during a pandemic is contingent on personal protective equipment (ppe) treating covid-19-off-label drug use, compassionate use, and randomized clinical trials during pandemics the equitable distribution of covid-19 therapeutics and vaccines uk healthcare regulator brands resuscitation strategy unacceptable covid-19: doctors are told not to perform cpr on patients in cardiac arrest key: cord-328873-yheimxhu authors: kassem, abdel meguid title: covid-19: mitigation or suppression? date: 2020-04-21 journal: arab j gastroenterol doi: 10.1016/j.ajg.2020.04.010 sha: doc_id: 328873 cord_uid: yheimxhu nan in spite of all scientific developments over the last decades, the world is hit by covid-19; totally unprepared. in an unprecedented challenge to mankind, healthcare systems all over the world are subjected to the most extreme pressure and are forced to fight against a viral disease we still do not know enough about. suddenly healthcare providers are overwhelmed with problems of diagnosing and screening a virus, managing a disease which has a spectrum that ends in ards and death and preventing the spread of infection with still no vaccine available. the demands for medical supplies and personal protective equipment (ppe) increased exponentially matching the exponential increase in the numbers of infected persons. some countries imposed marked restrictions on medical supplies and ppe. shortage in medications become evident. the supply chain in the health sector is threatened to collapse. of course, these extreme challenges affected all aspects of human life: social, political, economic, cultural, educational, religious and spiritual. human health and healthcare are becoming central, as they should have been not only to healthcare providers, but to everyone. every single individual is made responsible for the spread or prevention of the disease irrespective of one's practice or discipline. not only infectious disease experts, epidemiologists and icu specialists are involved in this challenge, but also each individual in every community: either as potential victim of covid-19 or as an actual or potential care provider to infected persons in a bigger sense. simply, the future of mankind is at stake! we are currently experiencing a unique situation in which science and scientists are getting all the attention of politicians, economists, clerics, media. . .etc. scientists are in a race against time to combat a potentially fatal disease which healthcare systems even in the most developed world have to surrender to. so there is no other option but science, science and science. therefore, it was not strange to find nowadays scientists often side by side with presidents, prime ministers and ministers. researchers are directly influencing decision making at highest levels without the usual ''switches" and ''relays" in bureaucratic systems. it is quite evident that one of the reports which had great impact on decision making during the current crisis is the report of neil ferguson et al. on the impact of non-pharmaceutical interventions (npis) to reduce covid-19 mortality and healthcare demands [1] . in their report, using a transmission model founded on an individual-based simulation model for pandemic influenza, the authors investigated the effects of 2 intervention strategies in a uk and a usa context: 1 -mitigation strategy with the aim of slowing down transmission but not necessarily stopping epidemic spread (reproduction number r not necessarily <1) with protection of more vulnerable groups and reducing the peak healthcare demand, 2 -suppression strategy in which epidemic spread is reversed to reproduction number (r) <1. interventions in the mitigation strategy would be case isolation, quarantine of household contacts of a case and social distancing of the elderly (>70 years). in the suppression group social distancing of all age groups, household quarantine and closing schools and universities are further interventions. in the mitigation strategy interventions have to be timely instituted (not too early) to give chance for herd immunity to develop. with the suppression strategy the more successful the interventions are applied the less possibility of herd immunity and hence another epidemic is expected later this year after relaxing the instituted interventions. the authors concluded that the mitigation strategy, although associated with a herd immunity would result in overwhelming the healthcare system in both the uk and the usa and that it will never be able to completely protect those at risk from severe disease or death and the resulting mortality would therefore still be high. although the authors used the model in the usa and uk context, decision makers and healthcare providers in many parts of the world were tempted to extrapolate the results in their own context. the hypothesis that the mitigation model with the herd immunity it implies is already de facto existing (with relatively limited and late interventions of social distancing deployed if any) is even more tempting. this is particularly the case in developing countries were fragile healthcare systems are already overwhelmed. this would, for example, explain the still limited numbers of diagnosed cases in most developing countries. this assumption can even be boosted by observations of increased and unexplained surge of upper and lower respiratory tract infections which are poorly documented, and which is claimed to have occurred in previous months. collectively this would argue for the development of a kind of a herd immunity described with the mitigation model of ferguson et al. which in turn means that the peak of the crisis is already historical. of course, such ''wishful thinking" ignores the relatively limited numbers of testing for covid-19 in such countries as well as morbidities and mortalities which pass unnoticed by the formal healthcare system in the respective country. this is not intended to undermine such a hypothesis but to alert to the need to fill knowledge gaps by facts and solid data. the extrapolation of models and assumptions made in a particular context in completely different settings would be imprudent unless enough data and evidence can be generated in the respective country. simple statistics can provide precious information even with the least resources available. demographic data of infected individuals, clinical history, laboratory and radiologic findings of diagnosed cases as well as seroepidemiological research, particularly the latter are important for prediction and planning. the world is unified again, unfortunately by an infectious threat which necessitates orchestrated international efforts. although political boundaries are closed to protect countries against the virus, scientists' exchange of ideas and results is extensive as never before and boundaries between disciplines and specialties, between researchers and politicians, between theory and practice are melting in this fierce combat. in: impact of non-pharmaceutical interventions (npis) to reduce covid-19 mortality and healthcare demand. imperial college covid-19 response team endemic medicine department, faculty of medicine, cairo university, egypt e-mail address: kassem@git.eg.net key: cord-291222-n8kgsz2e authors: park, benjamin j.; peck, angela j.; kuehnert, matthew j.; newbern, claire; smelser, chad; comer, james a.; jernigan, daniel; mcdonald, l. clifford title: lack of sars transmission among healthcare workers, united states date: 2004-02-17 journal: emerg infect dis doi: 10.3201/eid1002.030793 sha: doc_id: 291222 cord_uid: n8kgsz2e healthcare workers accounted for a large proportion of persons with severe acute respiratory syndrome (sars) during the worldwide epidemic of early 2003. we conducted an investigation of healthcare workers exposed to laboratory-confirmed sars patients in the united states to evaluate infection-control practices and possible sars-associated coronavirus (sars-cov) transmission. we identified 110 healthcare workers with exposure within droplet range (i.e., 3 feet) to six sars-cov–positive patients. forty-five healthcare workers had exposure without any mask use, 72 had exposure without eye protection, and 40 reported direct skin-to-skin contact. potential dropletand aerosol-generating procedures were infrequent: 5% of healthcare workers manipulated a patient’s airway, and 4% administered aerosolized medication. despite numerous unprotected exposures, there was no serologic evidence of healthcare-related sars-cov transmission. lack of transmission in the united states may be related to the relative absence of high-risk procedures or patients, factors that may place healthcare workers at higher risk for infection. t he epidemic of severe acute respiratory syndrome (sars) quickly spread worldwide in 2003. as of july 11, 2003, a total of 29 countries had reported 8,427 probable cases to the world health organization (1) . much of the disease worldwide was associated with hospital-based outbreaks (2, 3) . healthcare workers made up a large proportion of cases, accounting for 37%-63% of suspected sars cases in highly affected countries (4) (5) (6) . in the united states, the epidemic was limited; 74 probable and 8 laboratory-confirmed case-patients were reported, despite aggressive efforts at detection, particularly in groups at high risk. surveillance for symptoms of sars was recommended for all healthcare workers who were exposed to patients meeting the clinical case definition for suspected or probable sars (7) . due to the importance of healthcare facilities in transmission of sars worldwide, state and local health departments, together with the centers for disease control and prevention (cdc), conducted a review of u.s. healthcare workers exposed to patients positive for sars-associated coronavirus (sars-cov). our objectives were to characterize the types of exposures and infection-control practices that occurred in u.s. hospitals related to sars patient care and to determine the extent of sars-cov transmission to u.s. healthcare workers. this investigation focused on healthcare workers at highest risk for infection, in other words, those who had known unprotected exposure to laboratory-confirmed sars-cov-positive patients. an exposure was defined as any healthcare worker-patient interaction that occurred within droplet range (i.e., 3 feet). exposures were categorized as either unprotected or protected, depending upon whether full personal protective equipment was used. full equipment was defined as the use of all the personal protective equipment recommended for the care of sars patients, i.e., a full-length gown, gloves, n95 or higher respirator, and eye protection with goggles or a face shield (7, 8) . healthcare workers were identified by hospital infection-control practitioners and public health officials through informal interviews with hospital staff, by review of employee records, and by self-identification. in addition to the healthcare workers at highest risk, other healthcare workers of interest were included, such as those with multiple protected exposures and any who requested inclusion because of concerns about exposure. this investigation was conducted as part of the public health response to the sars outbreak. informed consent was obtained from healthcare workers before epidemiologic and clinical information and biologic specimens were collected. a standardized questionnaire was used to collect data on demographics, occupation, exposure characteristics, use of personal protective equipment, patient events to which the healthcare workers were exposed (e.g., coughing or vomiting), and presence during medical procedures. in addition, information was collected regarding any clinical signs or symptoms in the worker up to 10 days after exposure, including fever, cough, shortness of breath, or radiographically confirmed pneumonia. a single convalescent-phase serum sample was collected from healthcare workers at least 28 days after their last exposure to the patient. in some situations early in the outbreak, samples were collected between days 22 to 28 early in the outbreak, consistent with cdc recommendations at the time. serum samples were tested for anti-sars-cov serum antibodies by enzyme-linked immunosorbent assay (elisa) and indirect fluorescent antibody test (9) . data were entered into microsoft access and statistical analysis was performed with sas version 8.2 (sas institute, cary, nc). univariate analysis was performed by using two-sided fisher exact or mantel-haenszel chisquared test, as appropriate. a p value of <0.05 was considered significant. eight of the nine united states healthcare facilities in which sars-cov-infected patients were evaluated participated in the investigation. six of the eight sars-cov-positive patients visited or were hospitalized at these eight facilities. a total of 110 healthcare workers (range 4-36 healthcare workers per healthcare facility) participated in this follow-up investigation (table 1 ). this total represented approximately 85% of healthcare workers who were identified as being at high risk for infection. healthcare workers were exposed to these patients from march 15 to june 23, 2003. the median age of healthcare workers was 41 years (range 23-61), 75% were females, and 74% were caucasian ( table 2 ). the most common occupation was nursing staff (48%), and the most common work site was the medical ward (38%), followed by the emergency department (24%) ( table 2 ). preexisting medical conditions in the healthcare workers were infrequent (data not shown). each healthcare worker was exposed over a median of 2.0 days (range 1-14), during which a median of 3.0 interactions (range 1-50) with the sars patient occurred. of the 102 healthcare workers from whom complete data were available, 45 (44%) reported exposure without any type of mask; 72 (70%) had exposure without eye protection (table 3) . sixty-six healthcare workers (65%) reported that the patient was coughing during one or more patient-worker interactions. of these, 40% had at least one exposure without a respirator and 52% had at least one without gown, gloves, and eye protection. eleven (11%) reported interaction with a patient who had active diarrhea, and 1 (1%) reported exposure during patient vomiting (table 4) . healthcare procedures with high potential to generate droplets and aerosols were infrequent: 5 healthcare workers (5%) reported manipulating an airway, (i.e., performing endotracheal intubation or suctioning), and 4 (4%) reported being present during administration of aerosolized medications (table 4) . three healthcare facilities instituted full infectioncontrol precautions (i.e., full use of personal protective equipment and placement in an isolation room) on the first day the patient was seen. healthcare workers in these facilities reported significantly fewer unprotected exposures, in comparison to facilities where full sars precautions were not instituted on the first day (62% vs. 87%, p < 0.05). to assess adherence to infection-control practices, we identified healthcare workers who had all of their exposures only after full sars precautions were started. we identified 43 such workers, representing all of the healthcare facilities that instituted precautions. in these workers, lapses in infection control still occurred, with nearly half reporting unprotected exposures, including many with no eye protection (table 5) . clinical signs or symptoms developed in 17 healthcare workers (15%) after exposure to one of the laboratory-confirmed sars patients, most commonly cough (table 6) . convalescent-phase serum samples were available for 103 (94%) healthcare workers; none (0%) tested positive for sars-cov. during the outbreak, cdc recommended furlough for any exposed healthcare worker in whom symptoms developed within 10 days of last exposure. fifteen healthcare workers in this review (14%) were excluded from all or selected duties as a result of sars exposure. of these, seven reported symptoms (fever, respiratory symptoms, or radiographically confirmed pneumonia), and eight were asymptomatic. however, 10 symptomatic healthcare workers were not excluded from duty, including four nurses or nurses' aides and one physician. while healthcare-related outbreaks of sars forced hospital closings and mandatory quarantines in some countries, no such events were reported in the united states. our investigation demonstrates that although many u.s. healthcare workers had unprotected exposures, no documented transmission of sars-cov was found. in light of the numerous healthcare workers in our investigation with unprotected droplet-range exposures, lack of transmission in u.s. hospitals may have resulted from a relative absence of highly infectious patients or high-risk patient procedures. the mode of transmission of sars is unclear, but evidence suggests it may be spread by large-and mediumsized droplets spread within 3 feet (5, 10) . some studies show use of any mask was associated with lower odds of infection in healthcare-related clusters (10) . globally, outbreaks among healthcare workers have occurred after exposure to certain patients or at certain points during illness (3, (10) (11) (12) . for example, in singapore, five patients were identified early in the epidemic who had infected >10 contacts each (11) . the timing of exposure to ill patients also is critical; patients may be most infectious in the second week of illness, as some data suggest peak viral shedding occurs at day 10 (13). additionally, descriptive data suggest that severely ill patients may spread virus more efficiently, particularly if they are coughing or vomiting (12) . although coughing was frequently reported, vomiting was infrequent. in addition, patients seen in the united states, with the exception of one patient who required intubation, were generally not very ill. transmission may also be event-dependent. procedures such as intubations and medication nebulizers have been associated with healthcare-related outbreaks, even among protected healthcare workers (11, 12) . one such cluster occurred in toronto, where illness consistent with suspected or probable sars developed in nine healthcare workers who cared for a patient around the time of intubation, despite use of full personal protective equipment (12) . in the united states, potential droplet-and aerosol-generating procedures were infrequent: only one patient required mechanical ventilation, and few healthcare workers reported administering aerosolized medication or performing 1 0 (0) 0 (0) a sars, severe acute respiratory syndrome; hcws, healthcare workers; na, not available due to incomplete reporting. table 5 . unprotected exposures in healthcare workers exposed to laboratory-confirmed sars patients after full infection-control procedures were initiated (n = 43) a exposure type n (%) any unprotected exposure 21 (49) without eye protection 18 (42) without n95 or higher respirator 6 (14) direct contact without gloves 6 (14) a sars, severe acute respiratory syndrome. bronchoscopy. one notable exception was a worker who performed two endotracheal intubations before sars was diagnosed. however, despite wearing only an n95 mask and gloves, this healthcare worker did not become symptomatic or seroconvert. our study was subject to a number of limitations. first, enrollment of both healthcare facilities and healthcare workers was incomplete. one institution in which healthcare workers were exposed to two sars-cov-positive patients was not included. active surveillance performed by state and local public health officials, as well as hospital infection-control practitioners, identified no symptomatic healthcare workers among the exposed (j. rosenberg, pers. comm.). also, completeness of recruiting varied between institutions, although we had a high participation rate overall of approximately 85% of healthcare workers identified as being at high risk. as in all surveys, recall bias was a concern. however, given that no healthcare workers were sars-cov-positive and few had symptoms, the effect of outcome on recall was probably minimal. additionally, questions about hand hygiene and removal of personal protective equipment were not included because of concerns of overwhelming bias inherent in recalling such practices, although these factors may have been important. third, although most serum samples were obtained >28 days after last exposure to the sars patient, 19 (18%) samples were obtained during days 22 to 28. these samples were primarily collected early in the outbreak when the recommendation for convalescent-phase serum collection was set for >21 days after exposure. evidence from other studies shows that most case-patients case will seroconvert by day 20 (13) . although this elisa is currently used as a standard criterion and has unknown sensitivity, a similar assay has been reported to have an estimated sensitivity of approximately 93%, based on clinical case definitions for probable sars (13) . despite the limitations of the study, a number of insights were gained from this analysis that may help prepare public health officials and clinicians for a reappearance of sars, should it occur, or for the emergence of another infectious disease. rapid identification and isolation of potentially infectious persons undoubtedly will help minimize exposures. communication between public health officials and hospital infection control staff can help with efficient implementation of such control procedures. however, current levels of adherence to infectioncontrol practices in the united states may not be sufficient if many high-risk patients or procedures are encountered. unprotected exposures among healthcare workers may still occur despite implementation of facilitywide infection-control precautions. therefore, new initiatives for infection control should include measures to improve compliance with personal protective equipment overall, in addition to specifically focusing on patients and events that have the highest risk for transmission. update: severe acute respiratory syndrome-worldwide and united states a major outbreak of severe acute respiratory syndrome in hong kong comparative full-length genome sequence analysis of 14 sars coronavirus isolates and common mutations associated with putative origins of infection control measures for severe acute respiratory syndrome (sars) in taiwan investigation of a nosocomial outbreak of severe acute respiratory syndrome (sars) in toronto, canada severe acute respiratory syndrome: providing care in the face of uncertainty interim domestic guidance for management of exposures to severe acute respiratory syndrome (sars) for health-care settings outbreak of severe acute respiratory syndrome-worldwide a novel coronavirus associated with severe acute respiratory syndrome effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (sars) severe acute respiratory syndrome-singapore cluster of severe acute respiratory syndrome cases among protected health-care workers-toronto, canada clinical progression and viral load in a community outbreak of coronavirus-associated sars pneumonia: a prospective study we acknowledge the support and willingness of the healthcare workers who participated in this investigation; healthcare workers worldwide, whose efforts assisted in containing the spread of sars; and the following: felicia key: cord-330966-98sygj8n authors: barello, serena; palamenghi, lorenzo; graffigna, guendalina title: empathic communication as a “risky strength” for health during the covid-19 pandemic: the case of frontline italian healthcare workers date: 2020-06-24 journal: patient educ couns doi: 10.1016/j.pec.2020.06.027 sha: doc_id: 330966 cord_uid: 98sygj8n nan the covid-19 outbreak has been extraordinarily demanding for healthcare systems worldwide. during the first months of 2020, italy has faced one of the heaviest outbreak, with over 100179 confirmed cases and around 28884 deaths [1, 2] . furthermore the italian healthcare system was on the verge of total collapseat least in the regions most affected by the virus spread, such as lombardy -and more than 4,500 healthcare professionals were infected as of april 30. while specialized intensive care units in italy were overwhelmed by the increasing number of cases, healthcare providers who did not have expertise in infectious disease treatment stepped up to provide care for patients with covid-19 [1] . as the epidemic curve increased, many healthcare providers voluntarily joined the epidemic control efforts, and 1500 healthcare providers (including 300 physicians and 500 nurses) from across italy voluntarily came to the most affected italian regions to offer their support. unanimous -across healthcare specialties -was their sense of responsibility to relieve patients and families' suffering and the need to put coordinate efforts to safeguard the whole country from the virus spread. in the face of this unpredictable disease and its related safety risks, healthcare providers feared infection and worried about their loved ones, but they still joined the institutional call to give their professional contribution to contain the epidemic and showed a limitless spirit of empathy. finset and colleagues [3] suggested that this characteristic is expected to be a key factor in fighting the covid-19 pandemic in order to guarantee the healthcare systems' survival during and after this unprecedented healthcare crisis. nonetheless, although empathy is essential in patient-doctor interactions, it might also be a challenging task for clinicians, often helped by mutual trust [3] . indeed, the high exposure and involvement in emotionally distressing situations and the need to acknowledge patients and families' negative emotions risk to drain healthcare providers' psychological and physical resources with possible consequences on the long run [4, 5] . the authors of this letter encourage to take into serious consideration the fact that, while some studies have shown that clinicians' empathy positively impacts on quality of care, it should not be forgotten that more empathic clinicians might be at higher risk of distress [6] . we had proof of this phenomenon in a cross-sectional study that we recently conducted on 1150 italian health professionals during the early outbreak of the covid-19 italian pandemic. here, we summarize details of the 376 healthcare workers who directly assisted covid-19 patients. they were invited to fill an online questionnaire includingin addition to information on demographic and professionals aspects -the following items: self-report items designed to assess healthcare professionals' empathic attitude in terms of their perspective taking ability (e.g. item: a health care professional who is able to view things from another person's perspective can provide patients' with better care) and a list of psychosomatic symptoms adapted from the copenhagen psychosocial questionnaire [7] table 1 describes more in details the sample characteristics. results revealed that clinicians' higher empathy exposed them to suffer from more psychosomatic symptoms as demonstrated by significant correlations between the average experience of symptoms and the perspective taking score (r=.149, p=.008). this finding might complement reflections by finset and colleagues by adding knowledge about the implications of empathic communications for the clinicians' wellbeing and demonstrates its possible "side effects" as a "risky strength" of health professionals. the crucial role of healthcare providers in this unprecedented crisis is not in doubt; still healthcare professionals face great challenges and are at high risk of distress due to their empathic response. while attitude to empathy is an key personal feature of healthcare professionals and buffers the effects of burnout, it also seems to expose personnel to more frequent psychosomatic symptoms. our study provides early insight into the psycho-physical consequences that italian healthcare workers are experiencing. this shows the need to supply them with "psychological self-protective equipment" capable of mitigating the massive impact of this emergency on their actual and future wellbeing [8, 9] . post-pandemic research has suggested to provide healthcare workers with psychological supports based on models of psychological adjustment and resilience. the efficacy of debriefing and psychological first aid, help-lines and support groups for professionals has also been documented. healthcare institutions have ethical duties to reflect on the work-related stressors when the covid-19 emergency will be over [10, 11] . all authors had full access to all the data in this study and take responsibility for the integrity of the data and the accuracy of the data analysis. sb and lp contributed equally and share the corresponding authorship. sb conceived of and designed the study. lp run the analysis. sb and gg supervised data collection and analysis. all authors contributed to reviewing and editing the manuscript. we declare no competing interests. at the epicenter of the covid-19 pandemic and humanitarian crises in italy: changing perspectives on preparation and mitigation, catal. non-issue content covid-19 and italy: what next? effective health communication -a key factor in fighting the covid-19 pandemic burnout and somatic symptoms among frontline healthcare professionals at the peak of the italian covid-19 pandemic caring for health professionals in the covid-19 pandemic emergency : toward an " epidemic of empathy " in healthcare putting the altruism back into altruism: the evolution of empathy the copenhagen psychosocial questionnaire -a tool for the assessment and improvement of the psychosocial work environment italian doctors call for protecting healthcare workers and boosting community surveillance during covid-19 outbreak resilience training for hospital workers in anticipation of an influenza pandemic the effectiveness of psychological first aid computer-assisted resilience training to prepare healthcare workers for pandemic influenza: a randomized trial of the optimal dose of training the study we mentioned in this letter receive the approval by the ethic commission of the department psychology of the catholic university of milan -italy (irb n°: 04_2020) j o u r n a l p r e -p r o o f key: cord-282457-80htwxm0 authors: iserson, kenneth v. title: healthcare ethics during a pandemic date: 2020-04-13 journal: west j emerg med doi: 10.5811/westjem.2020.4.47549 sha: doc_id: 282457 cord_uid: 80htwxm0 as clinicians and support personnel struggle with their responsibilities to treat during the current covid-19 pandemic, several ethical issues have emerged. will healthcare workers and support staff fulfill their duty to treat in the face of high risks? will institutional and government leaders at all levels do the right things to help alleviate healthcare workers risks and fears? will physicians be willing to make hard, resource-allocation decisions if they cannot first husband or improvise alternatives? with our healthcare facilities and governments unprepared for this inevitable disaster, front-line doctors, advanced providers, nurses, ems, and support personnel struggle with acute shortages of equipment—both to treat patients and protect themselves. with their personal and possibly their family’s lives and health at risk, they must weigh the option of continuing to work or retreat to safety. this decision, made daily, is based on professional and personal values, how they perceive existing risks—including available protective measures, and their perception of the level and transparency of information they receive. often, while clinicians get this information, support personnel do not, leading to absenteeism and deteriorating healthcare services. leadership can use good risk communication (complete, widely transmitted, and transparent) to align healthcare workers’ risk perceptions with reality. they also can address the common problems healthcare workers must overcome to continue working (ie, risk mitigation techniques). physicians, if they cannot sufficiently husband or improvise lifesaving resources, will have to face difficult triage decisions. ideally, they will use a predetermined plan, probably based on the principles of utilitarianism (maximizing the greatest good) and derived from professional and community input. unfortunately, none of these plans is optimal. disasters recur on a regular basis. in any disaster, and especially in those caused by disease, the public expects healthcare professionals to be on the front lines. indeed, most healthcare professionals expect that of themselves and their colleagues. in most disasters, and certainly during the current covid-19 pandemic, frontline healthcare professionals face two key ethical issues: (1) whether to respond despite the risks involved; and (2) how to distribute scarce, lifesaving medical resources. in this paper, i discuss how healthcare healthcare ethics during a pandemic iserson existential threat of this new coronavirus early enough to fully prepare institutional, local, regional, national, and international mobilization and response. political expediency, hubris, scientifically ignorant leaders, and incomplete information led to this inadequate advance planning by minimizing the threat when it appeared, further delaying vital public health action. at this point, the most vital ethical decision in our war against an unseen enemy is the one over which each of us has direct control: will we stay to help in the fight? most disaster plans depend on physicians, nurses, support staff, and prehospital personnel to maintain healthcare's frontlines during crises. yet planners cannot automatically assume that all healthcare workers will respond. will our hospitals and clinics have enough physicians, advanced practitioners, nurses, technicians, maintenance, and administrative staff to keep the doors open, the computers running, the linens clean, the lights on, and the facilities safe? will our 9-1-1 systems still be able to dispatch medics, firefighters, and police? that depends on the iterative, possibly hourly or daily, decisions that each affected individual repeatedly makes. such decisions are not purely ethical, but rather are complex determinations based on religious and personal values, family and community responsibilities, health and financial stability, and risk assessment. in 2001, for example, the ama code of ethics was modified from "solemnly commit [ing] ourselves to apply our knowledge and skills when needed, though doing so may put us at risk" 1 to "physicians should balance immediate benefits to individual patients with ability to care for patients in the future." 2 the american college of emergency physicians, meanwhile, stated in its 2017 code of ethics for emergency physicians: ''courage is the ability to carry out one's obligations despite personal risk or danger. emergency physicians exhibit courage when they assume personal risk to provide steadfast care for all emergency patients, including those who are agitated, violent, infectious, and the like." 3 despite these professional ethical codes, nothingeither morally or legally-compels a response to risk-prone situations. other than military personnel, no one is required to respond to potentially life-threatening emergencies. professional oaths and codes may serve to guide practitioners, but they are not absolutes. the factors that guide people to respond are very personal; healthcare workers' individual behavior and that of our organizational, professional and political leadership can modify those factors to increase the number that are willing to respond. 4 the moral backbone of medical professionals-a duty to put the needs of patients first-may be tested as they determine whether to stay and carry out their professional roles or to step back and decrease their own personal risks. whether providers will stay depends on their own risk assessment and value system. the "duty to treat" when one's health, life, or personal well-being is threatened is not absolute. in a risk-prone situation, each of us will prioritize our personal and professional values, those traits in ourselves that we consider to be our fundamental driving forces. "most clinicians first assess the risks to our own and to our family's life, health, and safety. we may then factor in, to varying degrees, our religious beliefs and personal motivations, all colored by elements of our personality. next, we may consider professional factors, including the precepts in our healthcare profession's oaths and codes, as well as other ethical and religious dicta to which we subscribe. most clinicians will focus on their concrete professional responsibilities." 5 these professional factors include: • supporting/assuming the same risk as colleagues • collegial pressure/consequences of not helping • augmenting community welfare • fulfilling public expectation and trust • using societally underwritten special training and professional status • fulfilling implied consent to help those in need (social contract) emergency physicians may also feel that in these situations they are compelled to use their special knowledge about triage, allocation of scarce resources (eg, vaccines, prophylactic or treatment medications, or intensive care unit [icu] ventilators), public health mandates (eg, isolation or quarantine, or mandatory vaccination), and the use of altered standards of care. 4,6 when preparing for a disaster, planners should consider not how they expect people to respond, but rather why they are likely to respond. 7 the risks to physicians and other healthcare providers' will vary by the nature of the causative agent, the provider's activities and underlying health, and the protections offered and used. people decide which risks to accept or to avoid based on their own perceptions of the source and quality of the information they receive. 8, 9 quick, emotional impressions often precede and guide ''rational'' risk appraisals. 10 provider and population perception of their risk from covid-19 will probably not be congruent with reality. in part, this will be due to the discordant messages from many senior politicians and other officials, but also will be influenced by the realtime updates in scientific knowledge about the disease, its transmission, and possible protective measures. in crises, individuals must balance good information from valid media, government, and other sources to help identify the actual risks to themselves and their loved ones. providing the best current information about the risks as well as the opportunities to assist during a crisis will help healthcare professionals make defensible decisions in disaster settings. 5 transparent and consistent information generates the trust necessary for both caregivers and the population to develop a reasonable risk assessment during conditions of uncertainty. 11 issuing incomplete or conflicting information, as was done during the first months of the covid-19 outbreak, caused many providers to make decisions to respond based on heated emotions and inaccurate risk perceptions. people have been shown to naturally exaggerate the risk of phenomena that are unknown or "dreaded," such as those with delayed, irreversible or manmade effects; those that have new, unknown, or unobservable risks; those that are global; and those that are "hyped" by the media. 5 historical precedent and the nature of the medical profession demonstrate that we will have enough physicians and, probably, nurses to treat patients. other professional and non-professional staff needed to keep healthcare institutions operating may not be as willing to risk themselves. recent history suggests that we probably will not have enough support personnel because, although they may be at as much or more risk than healthcare professionals, their personal safety is often considered as an afterthought by administrators. "an important lesson from the sars outbreak is that, whereas most clinicians will ''stay and fight,'' vital support personnel, including those in materials and supply, logistics, cleaning, information technology communications, maintenance, and refuse removal, may feel no commitment to assist; moreover, they may feel undervalued, unprotected from risks, and ignored when they are omitted from vital communications." 12 if all the staff necessary to run medical facilities fail to receive timely, relevant and believable information, they may not respond, and the quality of available healthcare will deteriorate. widely distributing accurate risk assessments and descriptions of protective measures for staff will encourage the maximal number of clinicians and other necessary personnel to respond to the situation. therefore, disaster planners and managers should do everything possible to communicate the risks clearly to all members of the healthcare system and to provide them with as much support and security as possible. risk communication (figure 1 ) is "the exchange of real-time information, advice and opinions between experts and people facing threats to their health, economic or social well-being." 13 its purpose "is to enable people at risk to 14 in addition to providing information, research shows that to attain the maximal response during risk-prone and other disasters, planners must do everything practicable to mitigate perceived risks and to address other concerns that may prevent staff from being either able or willing to work in a disaster (table 1 ). to address one concern, on march 20, 2020, the american academy of emergency medicine issued a position statement saying, in part, that they believe "a physician, nurse, pa, first responder or other healthcare professional has the right to be removed from the schedule of work requiring direct contact with patients potentially infected with covid-19 for issues of personal health, such as being on immunosuppressive therapy or other similar concerns, without the risk of termination of employment." 15 rarely discussed, but a key part of maintaining our workforce, is to support the psychosocial needs of the healthcare team. according to medical anthropologist monica schoch-spana, "pandemics aren't just physical. they bring with them an almost shadow pandemic of psychological and societal injuries as well." 17 psychosocial support for healthcare workers in the current war against covid-19 will be akin to post-traumatic stress disorder treatment for soldiers manning the front lines for extended periods. people respond to the mitigating actions healthcare ethics during a pandemic risks differently, so experienced professionals will need to intervene before tragic, adverse events occur. in the current pandemic, some key resources are and will increasingly become scarce. physicians will need to consider how to distribute available resources and obtain or improvise others. the most ethical course of action is to do everything possible to delay having to ration. vital materials already in short supply include viral test kits and their associated equipment and reagents, personal protective equipment (ppe), ventilators, and hospital -especially icu -beds. while china rapidly erected new, prefabricated hospitals to treat patients and many countries around the world are establishing alternative care sites, the united states has been slow to act. often not considered, healthcare workers, especially those with expertise treating the critically ill, will inevitably become a scarce resource. however, as the situation changes, most healthcare workers will constantly reassess their decisions about responding. as increasing numbers of personnel get sidelined due to actual or suspected disease, exhaustion, or fear for themselves or their families. some active and retired personnel who initially stayed out of the fight or were sidelined due to illness or other circumstances may reassess their decision and join the battle. employing senior medical students and extending advance practitioners' scope of practice has been suggested as one way to ameliorate this problem. in england and wales, the national health service has asked about 65,000 retired doctors and nurses to return to work. in scotland, they are recalling those who retired within the past three years. if these clinicians have been away from practice for more than a short time, they will receive brief refresher training. 26 the institute of medicine, among others, have described how to best manage resource scarcity in a widespread disaster ( table 2 ). many of these strategies are discussed in more detail elsewhere. 27 during or after attempts at conservation, reutilization, adaption, and substitution are performed maximally, rationing will need to be implemented. 31 the ethical principle that guides rationing is distributive justice, which requires that scarce resources be distributed fairly, providing them to those most in need. specifically, it requires impartial and neutral decision makers to consistently apply rationing decisions across people and time (treating like cases alike). 32 this is based on utilitarian principles, including conservation of resources, fiduciary responsibility (stewardship), multiplier effect (does the person have a job that will save other lives?), immediate usefulness, medical success, and caretaker role. 33, 34 most ethicists agree, however, that such distribution should be equitable, although in some circumstances other distribution methods, such as first come, first served; equal distribution; and even, no distribution may be more rational. even with agreement about equitable distribution, scarcity often requires clinicians to prioritize which patients receive the resources. 33, 34 as the covid-19 pandemic extends its devastation, physicians around the world are already facing the daunting task of rationing lifesaving resources. this is upending their traditional method of treating the sickest first in emergency departments or "first come first served" in the icus. 31 in italy, physicians have reported limiting ventilators to those less than 60 years old, and china and spain have implemented medical resource rationing. the us government and many states that have developed rationing plans have yet to explicitly implement them. 35 many of these plans may be outdated, and none have been tested to determine whether they will save lives. in fact, a canadian study of h1n1 patients found that 70% of patients that a rationing plan would have removed from ventilators survived with continued ventilation. 36 dr. laura evans, an intensivist at the university of washington, is working with her state to devise a triage plan that would be doing "the most good for the most people and be fair and equitable and transparent in the process." yet the washington state health department recently issued a statement that "triage teams under crisis conditions should consider transferring patients out of the hospital or to palliative care if the patient's baseline functioning was marked by 'loss of reserves in energy, physical ability, cognition and general health.'" 36 rationing plans must conform to general ethical principles and to existing community moral standards. community input into these plans is vital for maintaining the public's trust in • prepare-e.g., anticipate challenges, develop plans, stockpile materials. identify leaders who can source or develop alternative supplies and equipment. identify and train risk communicators. plan to mitigate personnel difficulties in responding. • conserve-implement conservation strategies for supplies in shortage or anticipated shortage to ensure the minimum impact/compromise possible (e.g., determining "at-risk" groups with priority for therapies in shortage and overall strategies to conserve use of oxygen delivery devices [i.e., ventilators] or ppe. • substitute-provide an equivalent or near-equivalent medication or delivery device. • adapt-use of equipment for alternative purposes (e.g., anesthesia machine as ventilator) • re-use-plan to re-use a wide variety of materials after appropriate disinfection or sterilization (e.g., may include oxygen delivery devices). • re-allocate-if no alternatives exist, remove a resource from one area/patient and allocate to another who has a higher likelihood of benefit (i.e., greater chance of surviving or more post-disease years to live). healthcare ethics during a pandemic iserson clinicians, the institutions, and the organizations involved in disaster relief and resource allocation. a major ethical dilemma is that current rationing criteria may skew away from normally disadvantaged populations. in the past, allocation plans were developed by the healthcare community. in the current crisis, some planning groups have tried to address this by asking disparate communities throughout their region to offer input into the plans. 36 in all circumstances, rationing scarce medical resources is difficult and stressful. such distribution, rather than being based on politics, money or power, must be based on an equitable (fair), openly available, pre-existing plan. it may be beneficial to have emergency physicians and intensivists take the lead (under set protocols) in making these decisions, since they have had more experience than others in doing this on a regular basis. ideally, they will have support from their institutions' bioethics consultants, social workers, and chaplains. rationing will not end when medications to treat covid-19 are eventually identified or vaccines are produced for prevention. in the first weeks or months there will be limited amounts available, with massive public anguish over how they are being distributed. those involved in developing and implementing healthcare resource distribution will need to think ahead and include this eventuality in their plans. lastly, resource allocation is not the only option. disasters are the exact situations where clinicians and administrators need to "think outside the box" by expanding clinical roles and responsibilities, relaxing restrictive regulations, improvising medical equipment, and devising other solutions to scarcity. 27 until the pandemic ends, we will need to encourage our healthcare workforce to stay at their posts and to use their fortitude and intellect as they face the multiple challenges involved with their jobs. • physicians and other healthcare providers' individual risks will vary by the nature of the causative agent, the provider's activities and underlying health, and the protections offered and used. • provider and population perception of risk will probably not be congruent with reality. • history and the nature of the healthcare professions demonstrate that we will have enough professional personnel to treat patients. • history suggests that we will not have the necessary support personnel-unless we respect their jobs and their risks and communicate with them in an open and honest manner. • the distribution of scarce, lifesaving resources will first require searching for alternatives and then making triage decisions based on careful planning with, if possible, widespread input. declaration of professional responsibility ama code of medical ethics' opinion on physician duty to treat. opinion 9.067 -physician obligation in disaster preparedness and response available at: www.acep.org/ globalassets/new-pdfs/policy-statements/code-of-ethics-for-emergencyphysicians must i respond if my health is at risk? fight or flight: the ethics of emergency physician disaster response willingness of the local health department workforce to respond to infectious disease events: empirical, ethical, and legal considerations factors associated with the ability and willingness of essential workers to report to duty during a pandemic the social amplification of risk-assessing 15 years of research and theory the social amplification of risk: a conceptual framework feeling and thinking: preferences need no inferences iserson healthcare ethics during a pandemic heading into the unknown: everyday strategies for managing risk and uncertainty professional experiences-personal dangers. lecture given at the departments of emergency medicine and critical care michael's hospital world health organization. general information on risk communication available at: https:// www.youtube.com/watch?v=ramrf1huxyw aaem position statement on protections for emergency medicine physicians during covid-19. available at: www.aaem.org/resources/statements/position/ protections-for-eps-during-covid-19 centers for disease control and prevention. cerc in an infectious disease outbreak available at coronavirus will radically alter the u.s. the washington post. available at: www factors associated with the ability and willingness of essential workers to report to duty during a pandemic mitigating absenteeism in hospital workers during a pandemic factors associated with the willingness of healthcare personnel to work during an influenza public health emergency: an integrative review the role of risk perception in willingness to respond to the 2014-2016 west african ebola outbreak: a qualitative study of international healthcare workers will the nhs continue to function in an influenza pandemic? a survey of healthcare workers in the west midlands understanding the willingness of australian emergency nurses to respond to a healthcare disaster emergency medical services workers' willingness to work during pandemic influenza office of personnel management. pandemic information coronavirus: tens of thousands of retired medics asked to return to nhs. available at: www.bbc.com/news/uk-51969104 improvised medicine: providing care in extreme environments refining surge capacity: conventional, contingency, and crisis capacity crisis standards of care: a systems framework for catastrophic disaster response: volume 1: introduction and csc framework duty to plan: health care, crisis standards of care, and novel coronavirus sars-cov-2. national academy of medicine perspectives ethical considerations for decision making regarding allocation of mechanical ventilators during a severe influenza pandemic or other public health emergency ethical guidelines in pandemic influenza triage in medicine-part i: concept, history, and types triage in medicine-part ii: underlying values and principles coronavirus briefing: what happened today the hardest questions doctors may face: who will be saved? who won't? key: cord-323696-0lq8ql6n authors: bearman, gonzalo; pryor, rachel; vokes, rebecca; cooper, kaila; doll, michelle; godbout, emily j.; stevens, michael p. title: reflections on the covid-19 pandemic in the usa: will we better prepared next time? date: 2020-05-20 journal: int j infect dis doi: 10.1016/j.ijid.2020.05.059 sha: doc_id: 323696 cord_uid: 0lq8ql6n abstract the united states (us) spends more on healthcare than any other country with little evidence of better, or even comparable, outcomes. we reflect on the us and the covid-19 pandemic and focus on cultural, economic and structural barriers that threaten both current and future responses to infectious diseases emergencies. these include the us healthcare delivery model, the defunding of public health, a scarcity of infectious diseases physicians, the market failure of vaccines and anti-infectives and the concept of american exceptionalism. without institutionalizing the lessons learned, the us will be positioned to repeat the missteps of covid-19 with the next pandemic. the united states (us) spends more on healthcare than any other country with little evidence of better, or even comparable, outcomes. we reflect on the us and the covid-19 pandemic and focus on cultural, economic and structural barriers that threaten both current and future responses to infectious diseases emergencies. these include the us healthcare delivery model, the defunding of public health, a scarcity of infectious diseases physicians, the market failure of vaccines and anti-infectives and the concept of american exceptionalism. without institutionalizing the lessons learned, the us will be positioned to repeat the missteps of covid-19 with the next pandemic. states of america (us) exceeds 1.2 million infections and 78,000 deaths, the greatest count per country worldwide. 1 we reflect on the us and its response to the covid-19 pandemic and focus on cultural, economic and structural barriers that threaten both current and future responses to infectious diseases emergencies. the us spends more on healthcare than any other country, with little evidence of better, or even comparable, health outcomes. 2 in most developed nations, governments maintain universal access to healthcare services for citizens and coordinate resources across the span of the healthcare system. this central agency is able to effectively plan healthcare services, reduce inefficiency and develop infrastructure and workforce capacity to meet the population needs. 3 conversely, the us relies on a patchwork of public and private payors to finance healthcare delivery. 4 the fragmented us healthcare system also produces fragmented self-interests. health insurance agencies may seek to limit expenditures of insurance plan members in order to remain solvent, will only increase as americans continue lose their jobs due to the financial impact of covid-19. 6, 7 though the federal government has made assurances that healthcare systems will not bill uninsured patients for care related to covid-19, some uninsured patients have still received bills. 8 like many issues related to the american healthcare system, much of an uninsured person's bills are subject to the laws of the individual state in which a person resides. 9 a growing pool of unemployed, uninsured persons will almost certainly impact access to covid-19 testing with negative impact on transmission dynamics. this may result in significant numbers of undiagnosed people with minimal or mild symptoms, not under public health surveillance and contact tracing, transmitting the virus. the fragmentation, disparities in care and misaligned incentives do not provide a strong foundation for public health emergencies. a for-profit business model strives for maximal efficiency and minimal redundancy in supply chain structure. however, the global supply chain "just-in-time" manufacturing is not positioned to support the needs of page 5 of 16 j o u r n a l p r e -p r o o f 5 the healthcare system during a pandemic. this system has forced health care providers to resort to pleas on social media to secure personal protective equipment (ppe). 10 other developed countries, such as finland; effectively prioritized, funded and maintained adequate ppe stockpiles following the cold war, better positioning themselves for the threat of infectious diseases. 11 in the us, the federal government's response to covid-19 including invoking the defense production act (dpa), which requires industries to produce specific products (like ppe) needed to meet critical demands. yet procurement of raw materials for ppe production continues to be challenging for manufacturers. as the pandemic lengthens, supply management organizations increasingly feel severe disruptions. 12 the us federal government waivered on providing the centralized leadership to maximize the effectiveness of the dpa in obtaining raw materials and getting needed products to locations where they are needed most. 13 updating policies like the dpa must be a priority in an increasingly complex global economy. like most aspects of american governance, public health laws and mandates vary from state to state. the centers for disease control and prevention (cdc) provides guidance and recommendations to states but does not provide oversight. the cdc is able to enforce isolation and quarantine for specific communicable diseases in certain circumstances like interstate travel, 14 adequate funding is required to both incentivize id as a career track and to staff both health departments and infection prevention programs. antimicrobial resistance is a public health crisis. estimates predict that 10 million deaths per year related to antimicrobial resistance will occur beginning in 2050, coming at an enormous economic cost. 18 compounding this problem is a paucity of new antimicrobials in development against organisms designated by the world health organization as priority pathogens. 19 although government and non-governmental organizations have created incentives to encourage antibiotic research and development, pharmaceutical companies continue to abandon antibiotic discovery and development efforts. this is largely been because of concerns over a poor return on investment. 20 the current covid-19 pandemic highlights a complex and potentially vulnerable global supply chain for many pharmaceuticals, in addition to ppe. 21 the us has experienced critical supply shortages related to natural disasters in the past. in 2017, in the us, the food and drug administration (fda) oversees clinical diagnostics. at the start of the pandemic, testing was limited to the cdc, which developed and deployed an approved assay to state labs. state labs were unable to validate the assay, leading to significant delays in testing. inconsistent funding of public health programs contributed to covid-19 testing shortages. in late february 2020, the fda approved emergency use authorization allowing private laboratories to produce testing products to meet their diagnostic needs, but test shortages persist despite gradual increases in public and commercial test capacity. both germany and south korea mounted covid-19 responses with more speed, complexity and urgency than the united states. both countries quickly mounted largescale testing capabilities. this was a function of central oversight, coordinated healthcare delivery, public health infrastructure and public trust. within the first two months of diagnosing the first case of covid-19 in south korea, 600 testing sites had been set up, eventually allowing for 20,000 tests each day. 26 high testing volume allows asymptomatic, covid-19 individuals to self-isolate. in addition to testing large swaths of the population, south korean public health officials designed their test to detect the genetic targets recommended by the who. as of may 5, 2020, germany was able to test 120,000 people daily (population 83 million). 27 prior to the arrival of the covid-19 virus in germany, a german lab created a diagnostic test and published a "how to" online for other labs to use. 28 publishing the test "blueprint" allowed other german laboratories to create their own covid-19 tests, maximizing test availability. germany and south korea's responses to the covid-19 pandemic differ in many ways; but widespread, sustained testing allowed for prompt diagnosis, isolation and contact tracing in both countries. j o u r n a l p r e -p r o o f 10 a country's ability to prepare for a novel infectious disease relies on planning, sustaining and executing emergency response systems. this requires emergency preparedness as a national priority. within a loosely integrated and complex combination of private and public healthcare payers, commonly under a for-profit model, supply chain emergency response priorities must be uncoupled from business as usual and supported by state and federal funding. public health systems must be adequately funded and staffed to address both present and future infectious diseases threats. healthcare systems must incentivize infectious diseases and epidemiology as careers for graduates to meet current needs and coming plagues. the slow development of antivirals, antibiotics and vaccines is a market failure requiring robust public-private partnerships for sustained enhancement. will the us be better prepared for the next pandemic? resilience and ingenuity are part of the us cultural fabric, most notably demonstrated in the last century during world war ii. however, resilience and ingenuity are necessary yet not sufficient. without institutionalizing the lessons learned from covid-19, the us will be positioned to repeat the missteps of covid-19 with the next pandemic. the future of us emergency preparedness will reflect the wisdom of us political leader, inventor and intellectual benjamin franklin: "by failing to prepare, you prepare to fail." all named authors have seen and agreed to the submitted version of the paper. this editorial is original work and has not been submitted or published elsewhere. we have no conflicts of interest to report nor did we receive any funding for this editorial. no ethical approval is required by our institution for an editorial submission. higher spending, worse outcomes? the commonwealth fund mirror, mirror 2017: international comparison reflects flaws and opportunities for better u.s. health care. the commonwealth fund. updated july14 shortages resulted with health care providers often resorting to social media to secure personal protective equipment (ppe) what happens when our insurance is tied to our jobs, and our jobs vanish? the washington post up to 43m americans could lose health insurance amid pandemic, report says. the guardian covid-19 coverage for uninsured is underway, but more is needed. the american medical association got coronavirus? you may get a surprise medical bill, too. nbc news with covid-19, some states reopen the aca marketplace for uninsured health in international perspective: shorter lives, poorer health covid-19 survey: impacts on global supply chains. institute for supply management critical supply shortages -the need for ventilators and personal protective equipment during the covid-19 pandemic isn't worried about masks. the new york times legal authorities for isolation and quarantine kaiser family foundation. state data and policy actions to address coronavirus ready or not: protecting the public's health from diseases, disasters, and bioterrorism tackling drug-resistant infections globally: final report and recommendations. review on antimicrobial resistance priority pathogens and the antibiotic pipeline: an update what are the economic barriers of antibiotic r&d and how can we overcome them? coronavirus raises fears of u.s. drug supply disruptions. the washington post the shortage of normal saline in the wake of hurricane maria developing vaccines for sars-cov-2 and future epidemics and pandemics: applying lessons from past outbreaks american orientalism and american exceptionalism: a critical rethinking of us hegemony how is covid-19 affecting south korea? what is our current strategy? the new york times. germany coronavirus map and case count exception? why the country's coronavirus death rate is low. the new york times key: cord-023511-tvx4cflu authors: germain, sabrina title: will covid-19 mark the end of an egalitarian national health service? date: 2020-04-09 journal: nan doi: 10.1017/err.2020.33 sha: doc_id: 23511 cord_uid: tvx4cflu nan the exceptional circumstances brought about by the covid-19 pandemic have affected the traditional organisation of healthcare resources allocation in the uk. since its inception, the national health service (nhs) has aimed to regulate risks of ill health in the population by providing an equal and universal provision of healthcare services to residents based on their health status rather than their ability to pay. the rapid spread of this new virus has, however, triggered a shift in paradigm from an egalitarian allocation of healthcare resources to a utilitarian approach, which has led to discussions about society's greatest taboos: death and dying and the economic value of individuals' health. the rapid growth of covid-19 cases around the world has also highlighted the difficulties governments have had in dealing with the allocation of scarce resources. even though the nhs remains publicly funded, the provision of services is now ranking the needs of patients that are directly or indirectly affected by the virus rather than providing equal access to treatment for all. this paper argues that the current government's emergency healthcare policy has thereby favoured a utilitarian approach to healthcare rationing and potentially initiated the end of an egalitarian nhs. the paper first unpacks why the allocation of healthcare resources is fundamentally a question of justice in britain and explains why healthcare law and policy require a philosophical approach in times of crucial change and crisis. secondly, the paper provides a critical analysis of the current situation for the allocation of healthcare resources and the provision of services to patients directly or indirectly affected by the virus. it concludes that the liberal egalitarian conception of distributive justice at the heart of the nhs that aims to guarantee free and equal access to healthcare is now in jeopardy and is being replaced by a utilitarian approach based on a priority ranking of patients for the provision of services at this critical time. the resources available and mobilised for healthcare in the uk have been out of sync with the growing needs of society long before the surge of covid-19. 1 in fact, the scarcity of these resources has mandated patterns for their allocation ever since the inception of the nhs. 2 aneurin bevan, founder of the nhs, had established that healthcare resources had to be available universally based on patients' needs rather than their ability to pay, in order to stop ill health in the population after the war. this automatically placed the national institution within a framework of justice. 3 nonetheless, considerations around the basic entitlement to healthcare, whether resources should be allocated based on a patient's, a community's or a population's needs or whether the nhs should aim to provide individuals with greater life opportunity by satisfying healthcare needs, still to this day occupy the policy debate, and most particularly in this time of crisis. in theory, justice mandates that we treat equally those who are alike and those who are different in proportion to their differences. justice balances the needs and desires of individuals with the claims of the community. 4 it is concerned with human relationships in the social order and issues of distribution. distributive justice, as an element of justice, provides methods for the allocation of resources. moral political philosophers have called on different ideas of distributive justice such as liberal equality, utilitarianism, communitarianism and libertarianism to create appropriate allocation frameworks for healthcare. 5 each of these four conceptions of distributive justice can form the basis of a healthcare policy. at times, they are also merged to adjust the distribution of healthcare resources. granted, healthcare resources do not possess outstanding attributes in comparison to other health determinants. however, their moral significance derives from the role they play in our lives. the pattern chosen for their allocation must therefore focus on the attainment of justice. 6 it is the indisputability and seriousness of healthcare needs that make the distribution of these resources stand out from the allocation of any other consumer good. their importance stems from the potential they have to alleviate risk of illness, suffering and absolute harm. 7 in line with these theoretical considerations, the bedrock of liberal egalitarian justice on which rests the nhs aims to provide equal access to care through the availability of publicly financed services at the point of use. 8 the british population and explains in part why over the past 70 years the egalitarian core of the nhs has been adapted but has persisted in spite of major political and economic shifts. 9 even though crucial turning points at the national level have triggered healthcare reforms that embraced alternative ideas of justice, at times prescribing the use of utilitarian means or libertarian principles to achieve greater efficiency and guarantee equal access to care, the original egalitarian goals have not been compromised. 10 after the war, bevan was convinced that "illness should neither be an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune, the cost of which should be shared by the community". 11 there was also the necessity to respond to fear with a collective action led by the state. from the start, the nhs rested on ideas of fairness and equality and an understanding that resources had to be shared in order for the rich and the poor to have the same access to services. 12 all would be treated equally, even the most vulnerable patients, thanks to the redistribution of resources and a system of provision based on needs rather than means. the nhs was to level the healthcare "playing field" by providing more care to the least favoured and most vulnerable, as well as equal access to services for all other types of patients. 13 over the years, successive governments have had to reinterpret bevan's commitment because of diminishing resources and growing healthcare needs. the rationing of resources became an underlying theme in healthcare policy as early as the 1980s. the change in culture embracing libertarian and utilitarian methods in healthcare that was initiated at the beginning of the thatcher era 14 was taken forward by new labour in the 1990s and climaxed under the coalition government. the nhs principles of equality in healthcare were preserved, but a neoliberal approach started to be adopted for the delivery of healthcare services. 15 this historical evolution of ideas of justice in british healthcare is of interest when assessing the impact of changes brought by times of crisis. after brexit, 16 covid-19 is yet another crucial turning point for the nhs policy-makers having to react in 9 ibid. 10 14 in 1979, the thatcher government introduced competition and efficiency in social policy to fight overwhelming public expenditures. after a controversial review of the nhs, the conservatives introduced the purchaser-provider divide in healthcare. universality of care was preserved and equality in access was upheld, but resources simply had to be optimised to derive the greatest utility from a more "efficient" nhs in order to address the needs of vulnerable patients. see national health service and community care act 1990. 15 the health and social care act (2012) placed the patient at the heart of the system and medical professionals in a support role. the nhs principles of equality in healthcare were preserved, but a neoliberal approach to the delivery of healthcare services had been adopted. healthcare had become a fully fleshed market where the private sector was encouraged to compete with providers to offer the best and most cost-efficient services to patients. these changes shaped the place given to the independent sector (private and corporate entities) in the financing and provision of healthcare services in the twenty-first century. 16 urgency to a situation that may require them to leave behind its egalitarian foundations to embrace a more utilitarian approach to the provision of healthcare services. the current pandemic confronts the nhs with unprecedented demands and pressures with a direct effect on intensive care units and the medical workforce. 17 some groups of patients, such as the elderly and individuals affected by comorbidities, have recorded greater fatality rates; others affected by underlying socioeconomic inequalities that were at play prior to the spread of the infection are also more prone to contracting the virus. 18 nevertheless, the infection is "non-discriminatory" in nature, affecting all social statuses and affluences. 19 this does not, however, translate into a levelling of access to healthcare resources for all. 20 dramatic ethical dilemmas relating to resource allocation are thereby brought into sharper focus. the government has to determine how to allocate scarcer resources with the growing and urgent need to mitigate the impact on the nhs and the population. if the british healthcare system were to keep in line with its principles of egalitarian justice, healthcare services would be delivered equally to all similarly situated patients on the territory. this would entail that patients be treated alike regardless of whether or not they have contracted the virus. additional resources would, however, be provided to more vulnerable or critical patients in comparison to less urgent cases as an exception to this strict equality rule. 21 however, the reality of the pandemic does not allow for the system to spread out its resources in order to preserve equality. for instance, patients cannot be rotated to share ventilator time or bed days in hospital. the system therefore automatically reverts to a de facto "first come, first served basis" until resources are depleted. 22 in the near future, a critical juncture will be reached where clinicians will be forced to choose between providing life-sustaining conditions to patients or abandoning treatment. such concrete discussions around death and the cost associated with life-sustaining treatments have never been so pressing, but the race against the virus no longer allows for a pause to reflect on a collective decision around the allocation of healthcare resources in times of crisis. thus, the government, along with other 17 m morgan, "when the problem is urgent and important" (2020) bmj <https://www.bmj.com/content/368/bmj. m1062> (last accessed 31 march 2020). 18 see, generally, a resnick, s galea and k sivashanker, "covid-19: the painful price of ignoring health inequalities" (2020) bmj <https://blogs.bmj.com/bmj/2020/03/18/covid-19-the-painful-price-of-ignoring-health-inequities> (last accessed 31 march 2020). 19 the british prime minister boris johnson and his health secretary matt handcock have contracted the virus, proving that even the highest echelons of power could not be sheltered from this infection. 20 resnick, galea and sivashanker, supra, note 18. 21 the pioneering work of john rawls on liberal equality establishes that justice requires that all be treated equally and that inequalities be repaired with a system of distribution based on morally relevant factors. thus, according to rawls' difference principle, inequalities are permissible as long as they provide the greatest benefit to the least advantaged. see rawls, supra, note 13. 22 c pagel, m utley and s ray, "covid-19: how to triage effectively in a pandemic" (2020) bmj <https://blogs. bmj.com/bmj/2020/03/09/covid-19-triage-in-a-pandemic-is-even-thornier-than-you-might-think> (last accessed 24 march 2020). european counterparts, is operating a shift in healthcare policy towards a utilitarian model of rationing with equality in access as a second-rank priority. the aim is to maximise healthcare outcomes by favouring individuals with a greater chance of survival and introducing a ranking of patients. 23 for instance, on 21 march 2020, the national institute for health and care excellence (nice) has introduced, at breakneck speed, its covid-19 rapid guidelines to facilitate intensive care clinicians' assessment of patient needing to be admitted into critical care. the recommendations suggest that doctors consider the medical benefit, including the patient's likelihood of recovery from critical care admission, to an outcome that is acceptable. 24 the advice requires upstream decision-making upon the patient's admission and a certain level of speculation on how well they will respond to critical care. only time will tell whether these criteria have indirectly imposed age-based rationing in the sense that elderly patients tend to have a greater propensity for comorbidities and may be assessed as having less of a likelihood of recovery from critical care. at a philosophical level, our society also needs to decide whether forgoing equality in access to care for the elderly is a choice that needs to be made in a time of pandemic; whether these older patients have had their "fair innings" and should sacrifice their care for younger patients more likely to recover from the infection, 25 an approach that seems to have been taken by the current government. other vulnerable groups of patients also feel the repercussions of this change in allocation strategy, mostly patients suffering from chronic conditions such as diabetes or cancer. individuals in need of living-donor transplantation have also had their surgeries postponed or cancelled for fear that they would take up intensive care beds at post-op. routine check-up appointments have for some part moved online, but patients suffering from chronic illnesses that may require additional attention tend to refrain from asking for help for fear of overburdening the healthcare system. 26 at the diagnostic level, utilitarian considerations are also coming into play. as the uk entered the "delay" phase of its plan to fight covid-19 on 12 march 2020, policy shifted with regards to the testing of individuals at risk of having contracted the virus. the nhs no longer offered testing in the community and reserved the process to the hospital setting for immunocompromised and intensive care patients. 27 other patients with symptoms that did not require inpatient medical care were asked to self-isolate without an official diagnosis. 28 these measures were rolled out in parallel to a letter sent to primary care doctors that set out a list of activities to be halted or postponed in gp 23 d shaw, d harvey and d gardiner, "don't let the ethics of despair infect the intensive care unit" (2020) journal of medical ethics <https://blogs.bmj.com/medical-ethics/2020/03/26/dont-let-the-ethics-of-despair-infect-theintensive-care-unit> (last accessed 27 march 2020). surgeries. 29 equality in access to preventative medicine was thereby replaced to allocate scarce resources to individuals more at risk. in addition, in an effort to provide a centralised response to the crisis, the government has drafted emergency legislation. among other special stipulations, the coronavirus act encloses provisions to grant a temporary authorisation of practice to designated healthcare professionals and emergency volunteers. 30 the effort to rally a greater number of medical professionals raises other ethical questions that should be addressed in light of the new utilitarian approach to resource allocation. even though, after much pressure, the government took the decision to test healthcare workers showing symptoms, the lack of routine testing of key workers certainly endangers patients. 31 not aware of their health status, asymptomatic health workers may transmit the disease while providing care. 32 it may well be that we should now consider providing preferential treatment to this essential group of workers. in times of health emergency, it is important to guarantee that the medical forces be as fit as possible and in the event that they do fall sick that they return to work swiftly for the benefit of the population. simply put, prioritising healthcare professionals' wellbeing and treatment can be justified because it would help maximise the health outcome of the entire population. 33 most striking is the emphasis put by public powers on individual responsibility and collective action. without any available treatment or vaccine, the government sought to relieve pressure from the nhs by incentivising the public to adopt social distancing measures and for individuals to self-isolate if they suspected they have the virus. 34 in an effort not to detract resources from the healthcare system, british society could now reflect on another conception of distributive justice that would embrace communitarian approaches to rationing. communitarian thoughts and justice theories tend to focus on a balanced allocation of resources that takes into account a patient's illness but also the needs of the local community to achieve just outcomes for society as a whole. 35 if we are to think collectively about healthcare outcomes, we should also seriously account for underprivileged groups such as rough sleepers, drug users and the homeless during a pandemic. these groups are less likely to have access to the nhs as they are for most part unregistered residents and may not be able to practice daily hygiene, putting them at a greater risk of getting infected. 36 protection of vulnerable groups and at-risk patients is an upstream process that will require some redesign of current healthcare institutions after the pandemic. offering appropriate healthcare support to immigrant populations, improving sanitation and access to medical services in shelters as well as increasing access to care for people with disabilities are only a few examples of initiatives that must be put into place to protect these groups from future epidemics. 37 debates around who should meet their death first make us uneasy as a society. 38 this is in part the reason why we have missed out on an opportunity for a collective dialogue at the onset of the pandemic. we now leave some of the most tragic decisions in the hands of clinicians on the ground. 39 triage among incoming patients occurs on a daily basis; however, choices at a systemic level, such as the allocation of intensive care beds, ventilators and test kits among different hospitals, remain in the remit of the government. clinicians will continue to follow deontological principles and act in the best interests of their patients. these principles may sometimes conflict or work independently from governmental guidelines that dictate the allocation of resources at a macro level. 40 nonetheless, clinicians will have to adjust their clinical assessment to mitigate resources and maximise the greater good in line with the government's utilitarian healthcare policies. 41 all of these moral decisions cannot be made in silos; healthcare workers need support from their professional colleges and colleagues from other disciplines, among which are political theorists and bioethicists, to make the best judgement calls. 42 indeed, the pandemic has demonstrated that distributive justice and its different conceptions (egalitarianism, utilitarianism, communitarianism or libertarianism) are no longer confined to theoretical assumptions but anchored in reality and that they must be used as a first port of call to find models for the allocation of scarce resources. the second world war had brought about a national egalitarian institution for the care of the british people. the current "war" on the virus has given rise to a new wave of utilitarianism for the provision of healthcare services. with a realistic outlook on the situation it is clear that the aftermath is not in close sight, with a vaccine potentially only available in 12-18 months. the cost of having scaled up critical and intensive care on the entire territory and having purchased services and hospital beds in the independent sector will have long-term effects on nhs finances. going back to the egalitarian model that was already under strain prior to the advent of covid-19 will be practicably impossible, even if current utilitarian emergency policies are suspended. the nhs will nonetheless need to first address the delays in treatment that occurred during the time of the pandemic. second, the public health strategy will have to be reassessed to prepare for a potential future incident of a similar scale and to learn the lessons from the current episode. it is now time for us to accept that the nhs will face hard choices in the weeks, months and even years to come as a consequence of this devastating pandemic. unfortunately, some will be direct and others indirect victims of covid-19, for lack of critical and intensive care resources or because of delays in treatment. we should, however, remind ourselves that resources continue to be used to save as many lives as possible in order to offer all a fair and equal opportunity to pursue life plans upon recovery from an illness. 43 things may never go back to the way we knew them before this pandemic, especially with regards to the healthcare system and resources available. we are entering a new period that has triggered personal and collective grief for this loss of normalcy. 44 this overhaul may, however, have given us an opportunity to discuss as a society the resources we wish to allocate to the nhs in the future and the manner in which we believe it is most just to ration what is now available. 43 o goldhill, "ethicists agree on who gets treated first when hospitals are overwhelmed by coronavirus" (2020) quartz <https://qz.com/1821843/ethicists-agree-on-who-should-get-treated-first-for-coronavirus> (last accessed 27 march 2020). 44 s berinato, "that discomfort you're feeling is grief" (2020) harvard business review <https://hbr.org/2020/03/ that-discomfort-youre-feeling-is-grief> (last accessed 30 march 2020). covid-19: gps can stop health checks for over 75s and routine medicine reviews coronavirus: testing rolled out for frontline nhs the life and death decisions of covid-19 covid-19 and community mitigation strategies in a pandemic we can't be squeamish about death. we need to confront our worst fears the moral cost of coronavirus at the clinical level, bioethics philosophers generally believe that the healthcare decision-making process should revolve around four principles: autonomy, non-maleficence, beneficence and justice. in line with these principles, doctors select treatments based on an assessment of the disease and only then run a cost-benefit analysis for each treatment option covid-19 and the moral community: a nursing ethics perspective key: cord-340427-kirtoaf2 authors: misztal-okońska, patrycja; goniewicz, krzysztof; hertelendy, attila j.; khorram-manesh, amir; al-wathinani, ahmed; alhazmi, riyadh a.; goniewicz, mariusz title: how medical studies in poland prepare future healthcare managers for crises and disasters: results of a pilot study date: 2020-07-09 journal: healthcare (basel) doi: 10.3390/healthcare8030202 sha: doc_id: 340427 cord_uid: kirtoaf2 in the event of a crisis, rapid and effective assistance for victims is essential, and in many cases, medical assistance is required. to manage the situation efficiently, it is necessary to have a proactive management system in place that ensures professional assistance to victims and the safety of medical personnel. we evaluated the perceptions of students and graduates in public health studies at the medical university of lublin, poland, concerning their preparation and management skills for crises such as the covid-19 pandemic. this pilot study was conducted in march 2020; we employed an online survey with an anonymous questionnaire that was addressed to students and graduates with an educational focus in healthcare organization and management. the study involved 55 people, including 14 men and 41 women. among the respondents, 41.8% currently worked in a healthcare facility and only 21.7% of them had participated in training related to preparation for emergencies and disasters in their current workplace. the respondents rated their workplaces’ preparedness for the covid-19 pandemic at four points. a significant number of respondents stated that if they had to manage a public health emergency, they would not be able to manage the situation correctly and not be able to predict its development. managers of healthcare organizations should have the knowledge and skills to manage crises. it would be advisable for them to have been formally educated in public health or healthcare administration. in every healthcare facility, it is essential that training and practice of performing medical procedures in full personal protective equipment (ppe) be provided. healthcare facilities must implement regular training combined with practical live scenario exercises to prepare for future crises. rapid economic development combined with urbanization has led to significant human encroachment on the natural environment; this has exacerbated climate change, increasing the severity and frequency of extreme weather events that often result in morbidity and mortality [1, 2] . the covid-19 pandemic has exposed vulnerabilities in healthcare systems globally. it is imperative to review what healthcare managers are currently being taught to determine gaps in the curriculum to better prepare healthcare leaders for future disasters and pandemics. when crises occur, rapid and effective assistance to victims is essential. medical assistance is often necessary, and a significant number of victims require coordinated treatment and transport to healthcare facilities. the work of medical facilities cannot be carried out without an appropriate management system. therefore, managers of healthcare facilities must have the knowledge and skills needed to manage crises effectively [3] . in poland, public health is the only field of study that prepares potential healthcare managers. in recent years, this field of study has not attracted much interest as it does not have a standardized accredited curriculum or a defined set of competencies for healthcare administrators. in many high-, middle-, and low-income countries, schools of public health have developed competency-based curriculums focused on healthcare administration [4] [5] [6] . the healthcare institutions law states that a healthcare facility manager is a person who possesses higher education and has proper knowledge and experience to perform managerial duties [7] . the presented requirements indicate that the function of a manager in a healthcare facility can be performed by a person who does not necessarily have prior medical or managerial education specific to healthcare. management of healthcare organizations is complex. unlike most industries, unfamiliarity with healthcare operations may result in the director of a healthcare facility being unable to assess the risk of an epidemic or a disaster objectively. in turn, this may result in inadequate management and, consequently, may contribute to negative consequences for patients and staff of the medical facility. the aim of this study was to evaluate the perceptions of students and graduates in public health studies at the medical university of lublin, poland, concerning their preparation and management skills for crises such as the covid-19 pandemic. the standard of the polish medical training in 2019 may raise some concerns about the preparation of future medical staff in management of mass casualties resulting from major incidents and disasters, as well as an overwhelming amount of sick patients that can stress a healthcare system due to a pandemic. for example, the subject of disaster medicine is only included in the medical rescue course. the preparation of medical students for crises and infectious diseases at the medical university of lublin's department of public health is presented in table 1 . public health studies are not regulated in poland and therefore do not have a specific standard of education. it is the only field of study in poland that prepares potential healthcare managers. graduates from the medical university of lublin's department of public health curriculum are taught epidemiology, infectious diseases, and crisis management. during the students' first level of study (undergraduate studies), they are taught the following subjects: basics of epidemiology, virology, basics of sanitary-epidemiological monitoring, epidemiology, environmental epidemiology, basics of nosocomial infections, and crisis management. at the second level of studies (postgraduate studies), the subjects are disaster medicine, general epidemiology, nosocomial infections, and other threats. the current covid-19 pandemic necessitated revisiting the current preparedness in the polish medical facilities and among medical professionals for the next event. thus, we aimed to investigate the readiness level among trained professionals in public health with organizational knowledge in management of healthcare services. we conducted an extensive analysis of the literature. the findings were analyzed using the nominal group technique (ngt) and the acquired knowledge was sorted using categorization and knowledge mapping to develop a questionnaire. using instant messaging, the respondents had the opportunity to contact and ask questions if necessary. people working in healthcare facilities used this option to clarify the problems they encounter at work connected with the pandemic. an extensive analysis of literature and then the arrangement of the acquired knowledge through categorization and knowledge mapping led to the development of a research tool in the form of a questionnaire. a qualitative method was used to verify the research tool, and the questionnaire was tested on a sample of 6 students to check whether the respondents understood the questions it contained. this group was then excluded from the pilot study and their answers were not included in the final analysis. in the pilot study, an original questionnaire was available in online versions, which contained 6 closed questions and 2 questions that were open and allowed the respondents to express their opinions freely. statistical and frequency analyses, and review of basic descriptive statistics were conducted using ibm spss statistics version 26. the study was not a medical experiment and legally did not require the approval of the bioethics committee. the study involved 55 students and graduates, including 25.5% (14 subjects) men and 74.5% (41 subjects) women. among the respondents, 41.8% (23 subjects) currently worked in a healthcare facility and 58.2% (students) did not. among people working in healthcare facilities, only 21.7% (5 subjects) in the present workplace had participated in preparation training related for mass-casualty incidents and disasters (e.g., epidemics). in comparison, 78.3% (18 subjects) had not undergone such training. the respondents evaluated their workplaces' preparedness for pandemics on a likert scale from 0 to 10. table 2 presents the subjective evaluations of the respondents. most respondents rated the preparedness of their workplaces at three points (26%) and five points (26%), followed by 13% for six points, and 9% for zero points or one point. no one rated the preparedness of their workplace at the maximum of 10 points. the highest rating was seven points. however, some of the respondents worked in hospitals. in contrast, others worked in healthcare facilities such as outpatient clinics or primary care practices. in these workplaces, the risk is lower and advanced life-saving equipment, such as respirators, is not required in the workplace. as many as 96.4% (53 subjects) of the respondents acknowledged that healthcare managers should receive education and training concerning the management of healthcare facilities during emergencies and disasters, only 3.6% (two subjects) were of the opposite opinion. respondents were asked what kind of training should be included in the curriculum to develop competences and skills in crisis and disaster management. similar responses were grouped thematically. most often, respondents reported the need for practical classes and simulation of crisis events (26.44%), and some reported that these should be theoretical classes (13.79%). they proposed classes on the organization of the work of personnel and human resources management during crisis events (6.90%). they indicated that there should be more classes on the subject of crisis management (6.90%). furthermore, 6.90% of respondents reported the need for ppe training (learning to put on and take off suits, goggles, visors, and protective masks). the respondents reported that they never had the chance to put on or see others put on ppe during their studies, so they did not know how to use it properly and safely at work. they reported significant difficulties in performing patient care and the need to practice procedures in full ppe beforehand, as the range of movement in such situations is limited. only two of the respondents expressed that they did not feel the need for any additional training. respondent answers are presented in table 3 . the majority of the respondents (49 subjects) responded that healthcare management students should educate themselves about climate change and its impact on health. in the second question, where respondents were free to express their opinion by submitting an answer, they were asked to state their concerns if they did not have sufficient skills or competencies to manage crises as a current/future healthcare facility manager. the respondents (25%) were most often afraid that they would not be able to cope with the situation and that they would not be able to predict the development of the situation and make the right decisions. nearly 15% of the respondents were worried about the lack of experience in such situations, and 13% were afraid that the competencies they had would not be sufficient to manage a crisis. all of the respondents' answers are presented in table 4 . table 4 . concerns the respondents felt about their ability to manage a crisis independently. answers % concerns about the proper functioning of the facility 4 5.88% ability to allocate responsibilities well among employees 4 5.88% the stress of endangering the life and health of a large group of patients and staff 6 8.82% fears that their competencies are not insufficient 9 13.24% fear that i will not be able to cope, that i will not anticipate the development of the situation, and the fear of chaos 18 25 .00% concerns about the lack of experience in such situations 10 14 .71% concern about the lack of specific procedures 5 7.35% fear of responsibility and fear that i will make a mistake 6 8.82% the fear that i will become infected with an infectious disease 1 our findings suggested that among the respondents who worked in healthcare facilities, as many as 78.3% had not received any training related to preparation for crises and disaster. similar research was conducted in yemen in 2017, where 531 healthcare workers were surveyed using a questionnaire. the analysis showed that the general state of knowledge of yemeni healthcare workers was insufficient in relation to crisis and disaster preparedness. a total of 41% of all respondents had not participated in any disaster preparedness courses, and 58.9% of respondents had not participated in any practical exercises on crisis and disaster preparedness. additionally, managers seemed insufficiently qualified in emergency planning and crisis management, as their level of knowledge was lower than that of the medical personnel [9] . in poland, the first diagnosed covid-19 patient (patient zero) was recorded on 4 march, 2020 [10] , whereas in china, according to official sources, the first patient was diagnosed on 8 december, 2019 [11] . in poland, during those three months before the coronavirus was diagnosed and reported, people had started to buy mainly protective masks and thermometers. large quantities of ppe (e.g., protective masks, gloves, thermometers) were exported to china, as there was a huge demand in this region. due to this, a few weeks before the coronavirus's appearance in poland, the amount of available ppe was insufficient. the biggest problem turned out to be the lack of ppe for medical personnel. until then, hospitals that rarely had to deal with highly infectious diseases did not have a sufficient quantity of protective clothing, visors, or appropriate protective facemasks at their disposal. managers of healthcare facilities had not anticipated such a problem, most of them had no supplies, and the situation was a complete surprise to them. respondents working in the hospitals reported that visitors of hospitalized persons were taking protective gloves and disinfectant supplies out of the wards. a mandatory total ban on visits was introduced shortly after the first covid-19 patient's appearance, which brought an end to this practice. donors and community members came to the rescue, sewing masks and making homemade visors in a spontaneous gesture of help. an important problem, which the respondents pointed out, was the training on ppe use. wax and christian outlined the correct use of ppe for medical personnel, including guidelines on how to safely remove their protective clothing to not expose themselves to secondary contamination. the researchers stressed the need to define clear protocols for cleaning ppe for subsequent use [12] . according to the united states occupational safety and health administration (osha), it is essential for medical personnel to know the requirements for a given emergency [13] . these guidelines should serve as a basis for national protocol development in the standardized use and training of ppe in medical facilities. most respondents, when asked to express their concerns about being able to manage a healthcare facility in a crisis situation independently, indicated a lack of experience in such circumstances, a fear that their competencies would prove insufficient, and an inability to predict the development of the situation and to manage it properly. management in crises is difficult, stressful, and raises several concerns. unfortunately, a review of polish and foreign literature on the management of healthcare facilities in crises has shown that there is a paucity of published research in this area [14, 15] . a significant problem reported by the respondents is the need for training in operations management and human resource management. nowadays, in a healthcare organization's preparation for crises and disaster, the human factor plays a vital role. a shortage of medical personnel, high workloads, an increasing amount of documentation, and the fulfillment of several necessary formalities make medical practitioners reluctant to participate in training [16] . complacency also plays a contributing factor during a prolonged period of relative calm when no unexpected events occur. in this case, it can be difficult to expect staff to familiarize themselves with the documentation, standard procedures, and plans of mass-casualty incidents and disasters. in most cases, it consists of a quick, cursory review. in times of prolonged periods of security, people do not feel an imminent threat and, therefore, do not have the strong motivation to prepare for a crisis. the situation related to the spread of covid-19 is unprecedented and difficult for all managers [17] . the creation of hospital crisis management plans, evacuation plans, or handling of mass-casualty incidents, and the obligation for staff to become familiar with them, is an important step toward preparedness for these events. however, the lack of such plans can lead to chaos and complete disorientation. the effects of disasters can be mitigated by adopting risk management measures and appropriate planning, education, and training measures [18] . the most frequently mentioned need identified by students and graduates in public health was additional training (26.5%), which was based on practical exercises and simulations of real crises. the foundation for effective healthcare operations management should consist of regularly scheduled exercises and training in the procedures related to crises. skills rehearsed in practice improve preparedness and confidence, allowing one to verify knowledge and analyze the effectiveness of their actions, all of which cannot be achieved using only theoretical training or assumptions [19, 20] . a significant number of respondents, 89.1% (49 persons), felt that healthcare management students should receive education about climate change and its impact on health. many threats result from global climate change. these threats are caused mainly by rapidly developing industries and excessive human expansion into nature, raising the probability of various types of types of extreme weather events and new diseases, including infectious diseases and cancers, and their occurrence is increasing. the world health organization (who) identified climate change impacts on health and epidemics as the most urgent health challenges in the next decade [21] . medical and management personnel should be prepared for the possibility of an event that will exceed the local response capacity and lead to excessive morbidity and mortality [22] [23] [24] . the approach to crisis management issues adopted by the manager of a healthcare facility is an essential and decisive aspect. if a healthcare facility's management approaches the problem of preparedness for crisis incidents seriously, it can force the employees to read the documentation and participate in practical exercises [25] . this can be achieved by organizing several rounds of practical exercises so that all employees can participate. in addition, management should carry out tests to check employees' knowledge of plans and procedures for dealing with mass-casualty incidents and disasters, evacuation of buildings, and dealing with infectious diseases. if the head of the healthcare facility treats these issues as important, hospital staff will address them in the same manner [20] . healthcare organizations are challenging to manage on a day to day basis. a crisis event creates additional operational issues that require specialized knowledge and skillsets to manage effectively and safely. poland should consider increasing healthcare threats to its citizens as a catalyst to introduce new a curriculum in healthcare administration. at the undergraduate and graduate levels, programs can be created that develop competencies in disaster management and crisis leadership to prepare the workforce to manage future healthcare emergencies resulting from epidemics, natural disasters, or man-made events such as terrorism [26] [27] [28] [29] [30] . the main limitation of this study was that only one university was surveyed. however, it was a pilot study that revealed gaps in training and education related to crisis and disaster management in the public health studies curriculum, one that is preparing students to manage and lead healthcare organizations. to date, no similar research has been conducted in poland. this research forms the basis for planned future studies with more respondents and a more comprehensive approach aimed to determine the preparedness and training of healthcare administrators currently managing healthcare facilities in poland. another limitation is the low number of respondents in total. however, as a pilot mixed methods study, the outcome indicates a need for further studies with a larger population. managers of healthcare facilities should have the knowledge and skills to manage crises. they should have an education in public health with core courses in healthcare management. the public health curriculum should also develop competency-based programs that build knowledge and skillsets for managers to deal with emergencies and disasters effectively. training in ppe use and exercises in performing medical procedures in full protective clothing should be mandatory in all medical facilities. in poland, regular tabletop and live scenario exercises must be an integral operational consideration for all healthcare facilities to remain prepared for future crisis management of major incidents, disasters, and public health emergencies is complex and requires a multidisciplinary approach. future managers of healthcare facilities should be taught public health and medical knowledge but also be trained to collaborate, cooperate, and communicate effectively during a crisis. developing a competency-based healthcare management program together with regular tabletops and scenario-based simulation training should be considered to facilitate and improve the future polish preparedness for disasters and pandemics. natural disasters, climate change, and their impact on inclusive wealth in g20 countries challenges in implementing sendai framework for disaster risk reduction in poland education in disaster management and emergencies: defining a new european course emergency response to and preparedness for extreme weather events and environmental changes in china the new frontier of public health education the new harvard doctor of public health: lessons from the design and implementation of an innovative program in advanced professional leadership the polish sejm. act of 15 april 2011 about medical activities on the standards of education preparing for the profession of a doctor, dentist, pharmacist, nurse, midwife, laboratory diagnostician, physiotherapist and paramedic emergency and disaster management training; knowledge and attitude of yemeni health professionals-a cross-sectional study public health interventions to mitigate early spread of sars-cov-2 in poland epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study neurosurgery in an infant with covid-19 coronavirus and the eyes. the possibilities of infection transmission, clinical symptoms and prophylaxis in the ophthalmic office impact of the doctor deficit on hospital management in poland: a mixed-method study current response and management decisions of the european union to the covid-19 outbreak: a review postgraduate education in disaster health and medicine. front evacuation from healthcare facilities in poland: legal preparedness and preparation validated ways of improving the ability of decision-making in emergencies; results from a literature review population health adaptation approaches to the increasing severity and frequency of weather-related disasters resulting from our changing climate: a literature review and application to charleston, south carolina air pollution, climate change, and health disaster early warning systems: the potential role and limitations of emerging text and data messaging mitigation capabilities tools and checklists used for the evaluation of hospital disaster preparedness: a systematic review cognizant healthcare logistics management: ensuring resilience during crisis covid-19 epidemic in the middle province of northern italy: impact, logistics, and strategy in the first line hospital how should u.s. hospitals prepare for coronavirus disease 2019 (covid-19)? disaster preparedness and professional competence among healthcare providers: pilot study results bioterrorism preparedness and response in poland: prevention, surveillance, and mitigation planning the authors declare no conflict of interest. key: cord-347605-6db4gwhk authors: vento, sandro; cainelli, francesca; vallone, alfredo title: violence against healthcare workers: a worldwide phenomenon with serious consequences date: 2020-09-18 journal: front public health doi: 10.3389/fpubh.2020.570459 sha: doc_id: 347605 cord_uid: 6db4gwhk nan verbal and physical violence against healthcare workers (hcws) have reached considerable levels worldwide, and the world medical association has most recently defined violence against health personnel "an international emergency that undermines the very foundations of health systems and impacts critically on patient's health" (1) . two systematic reviews and meta-analyses published at the end of 2019 found a high prevalence of workplace violence by patients and visitors against nurses and physicians (2) , and show that occupational violence against hcws in dental healthcare centers is not uncommon (3) . in the first study (2) , the authors systematically searched pubmed, embase, and web of science from their inception to october 2018, and included 253 eligible studies (with a total of 331,544 participants). 61.9% of the participants reported exposure to any form of workplace violence, 42.5% reported exposure to non-physical violence, and 24.4% experienced physical violence in the past year. verbal abuse (57.6%) was the most common form of non-physical violence, followed by threats (33.2%) and sexual harassment (12.4%). the prevalence of violence against hcws was particularly high in asian and north american countries, in psychiatric and emergency departments, and among nurses and physicians (2) . in the second study (3), a systematic review and analysis of the literature was done using pubmed, sciencedirect, scopus, web of science, cochrane library and proquest. original articles published between january 1992 and august 2019 and written in english were included in the analysis. the violence experienced by dental healthcare workers was both physical and nonphysical (shouting, bullying, and threatening) and also included sexual harassment (3) , and in most cases, male patients, or coworkers were responsible. violent events ranged from 15.0 to 54.0% with a mean prevalence of 32%, and physical abuse ranged from 4.6 to 22% (3). most recently, the world medical association has condemned the increasingly reported cases of health care workers being attacked because of the fear that they will spread sars-cov-2. the situation in india is particularly shocking, with health care workers stigmatized, ostracized, discriminated against, and physically attacked, but incidents have been reported across the world, for instance from france, mexico, philippines, turkey, uk, australia, and usa (4, 5) . the recent systematic reviews and meta-analyses and the world health organization condemnation of the attacks against hcws treating patients with covid-19 have confirmed the seriousness of the situation regarding violence against doctors and nurses worldwide. many countries have reported cases of violence, and some are particularly affected by this problem. a chinese hospital association survey collecting data from 316 hospitals revealed that 96% of the hospitals surveyed experienced workplace violence in 2012 (6) , and a study done by the chinese medical doctor association in 2014 showed that over 70% of physicians ever experienced verbal abuse or physical injuries at work (7) . an examination of all legal cases on violence against health professionals and facilities from the criminal ligation records 2010-2016, released by the supreme court of china, found that beating, pushing, verbal abuse, threatening, blocking hospital gates, and doors, smashing hospital property were frequently reported types of violence (8) . in india, violence against healthcare workers and damage to healthcare facilities has become a debated issue at various levels (9) , and the government has made violence against hcws an offense punishable by up to 7 years imprisonment, after various episodes of violence and harassment of hcws involved in covid-19 care or contact tracing (10) . in germany, severe aggression or violence has been experienced by 23% of primary care physicians (11) . in spain, there has been an increase in the magnitude of the phenomenon in recent years (12) . in the uk, a health service journal and unison research found that 181 nhs trusts in england reported 56,435 physical assaults on staff in 2016-2017 (13) . in the usa, 70-74% of workplace assaults occur in healthcare settings (14) . in italy, in just one year, 50% of nurses were verbally assaulted in the workplace, 11% experienced physical violence, 4% were threatened with a weapon (15); 50% of physicians were verbally, and 4% physically, assaulted (16) . in poland, czech republic, slovakia, turkey many nurses have been physically attacked or verbally abused in the workplace (17) . according to the south african medical association, over 30 hospitals across south africa reported serious security incidents in just 5 months in 2019 (18) , and in cape town violence against ambulance crews is widespread (19) . in iran, the prevalence of physical or verbal workplace violence against emergency medical services personnel is 36 and 73% respectively (20) . the world health organization lists australia, brazil, bulgaria, lebanon, mozambique, portugal, thailand as other countries where studies on violence directed at hcws have been conducted (21) . the consequences of violence against hcws can be very serious: deaths or life-threatening injuries (15) , reduced work interest, job dissatisfaction, decreased retention, more leave days, impaired work functioning (22) , depression, post-traumatic stress disorder (23), decline of ethical values, increased practice of defensive medicine (24) . workplace violence is associated directly with higher incidence of burnout, lower patient safety, and more adverse events (25) . which are the most at-risk services and what are the underlying factors of this growing violence? emergency departments, mental health units, drug and alcohol clinics, ambulance services and remote health posts with insufficient security and a single hcw are at higher risk. working in remote health care areas, understaffing, emotional or mental stress of patients or visitors, insufficient security, and lack of preventative measures have been identified as underlying factors of violence against physicians in a 2019 systematic review and meta-analysis (26) . in public hospital/services, insufficient time devoted to patients and therefore insufficient communication between hcws and patients, long waiting times, and overcrowding in waiting areas (27) , lack of trust in hcws or in the healthcare system, dissatisfaction with treatment or care provided (26), degree of staff professionalism, unacceptable comments of staff members, and unrealistic expectations of patients and families over treatment success (28) are thought to contribute. indeed, in public hospitals worldwide, staff shortages prevent front-line hcws from adequately coping with patients' demands. in private hospitals/services, too extended hospital stays, unexpectedly high bills, prescription of expensive and unnecessary investigations are key factors. finally, the media frequently report extreme cases of possible malpractice and portray them as representative of "normal" practice in hospitals (24) . what can be done to reduce the escalating violence against hcws? hcws worldwide generally advocate for more severe laws, but harsher penalties alone are unlikely to solve the problem. importantly, evidence on the efficacy of interventions to prevent aggression against doctors is lacking, and a systematic review and meta-analysis found that only few studies have provided such evidence (29) . just one randomized controlled trial indicated that a violence prevention program decreased the risks of patient-to-worker violence and of related injury in hospitals (30) , whereas contrasting results in violence rates after implementation of workplace violence prevention programs have been observed from longitudinal studies (29) . there is no evidence on the effectiveness of good place design and work policies aimed to reduce long waiting times or crowding in waiting areas (29) . more studies are clearly needed to provide evidence-based recommendations, and interdisciplinary research with the involvement of anthropologists, sociologists, and psychologists should be encouraged. however, certain measures have to be taken and can be corrected, should they be shown as ineffective in properly conducted studies. security measures have been advocated for years (31) and should be taken to safeguard particularly the most at-risk services. first, staff shortages, so common in public hospitals worldwide, should be acted upon, and increased funding should be allocated to employ more doctors and nurses. hence, the duration of each patient encounter would be augmented, particularly in overburdened public hospitals, allowing the (often young) (32) doctors to develop a meaningful relationship with the patient. second, healthcare organizations and universities should considerably improve the communication skills of current and future hcws to reduce unrealistic expectations or misunderstanding of patients and families. third, hcws who denounce any verbal or physical violence should be fully supported by their healthcare organizations; this would reduce the huge issue of under-reporting of workplace violence (33, 34) . good courses should be organized for hcws to learn how to identify early signs that somebody may become violent, how to manage dangerous situations, and how to protect themselves. prompt communication about delays in service provision should be given to patients and their relatives when waiting times are long because certain conditions are prioritized. alarms and closed-circuit televisions should be placed in the higher-risk departments and in areas where doctors and/or nurses work in isolation. sanctioning of violence by patients, relatives or visitors must be imposed. staff should be increased and security officers should be placed, particularly at night, in remote health posts and emergency departments and at particular times (violence tends to happen in the evenings/nights, when more patients under the influence of drugs and alcohol present); the number of night shifts should be limited (23) . efforts should be made to improve job satisfaction of hcws (25) . finally, media should cease to contribute to the general public's distrust toward hcws and institutions. many patients report their negative experiences of medical care to news or media outlets which are highly interested in these stories and very often do not check the information before publishing it (24) . these biased media reports may exacerbate the tension. all workers have a right to be safe on their job, and healthcare workers are no exception. the idea that violence is inherent to doctors and nurses' work, especially in certain departments, needs to be fought; urgent measures must be implemented to ensure the safety of all hcws in their environment, and the needed resources must be allocated. failure to do so will worsen the care that they are employed to deliver and will ultimately negatively affect the whole healthcare system worldwide. sv had the idea of writing the manuscript and drafted it. fc co-drafted the manuscript. av contributed to the drafting, and reviewed the manuscript. all the authors approved the final version. covid-19 pandemic response prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis prevalence and policy of occupational violence against oral healthcare workers: systematic review and meta-analysis available online at attacks against health-care personnel must stop, especially as the world fights covid-19 stop violence against medical workers in china workplace violence and its aftermath in china's health sector: implications from a crosssectional survey across three tiers of the health system violence against health professionals and facilities in china: evidence from criminal litigation records academic college of emergency experts and academy of family physicians of india position statement on preventing violence against healthcare workers and vandalization of health-care facilities in india covid-19: indian government vows to protect healthcare workers from violence amid rising cases aggression and violence against primary care physicians -a nationwide questionnaire survey agresiones a profesionales del sector sanitario en españa, revisión sistemática. [aggression to health care personnel in spain: a systematic review guidelines for preventing workplace violence for healthcare and social service workers (osha workplace violence in the health sector. world health organization survey questionnaire onu. rapporto italia. rome (2019) un medico su due ha subito aggressioni. i dati preliminari dello studio fnomceo sancho cantus d. violence against nurses working in the health sector in five european countries-pilot study more than 30 sa hospitals report serious security incidents in past 5 months paramedics, poetry, and film: health policy and systems research at the intersection of theory, art, and practice prevalence of workplace violence types against personnel of emergency medical services in iran: a systematic review and meta-analysis world health organization. violence against healthcare workers workplace violence is associated with impaired work functioning in nurses: an italian cross-sectional study workplace violence against healthcare workers in emergency departments. a case-control study medical malpractice, defensive medicine and role of the "media" in italy addressing risks of violence against healthcare staff in emergency departments: the effects of job satisfaction and attachment style prevalence of type ii and type iii workplace violence against physicians: a systematic review and meta-analysis violence towards healthcare workers: a study conducted in abha city, saudi arabia violence against physicians and nurses in a hospital: how does it happen? a mixed-methods study interventions to prevent aggression against doctors: a systematic review preventing patient-to-worker violence in hospitals: outcome of a randomized controlled intervention tackling violence against health-care workers physical violence against doctors: a content analysis from online indian newspapers unreported workplace violence in nursing underreporting of workplace violence: comparison of self-report and actual documentation of hospital incidents the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 vento, cainelli and vallone. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-323489-ro7kbnu3 authors: arenas, maría dolores; villar, judit; gonzález, cristina; cao, higinio; collado, silvia; barbosa, francesc; crespo, marta; horcajada, juan pablo; pascual, julio title: protection of nephrology health professionals during the covid-19 pandemic date: 2020-10-06 journal: nan doi: 10.1016/j.nefroe.2020.06.018 sha: doc_id: 323489 cord_uid: ro7kbnu3 the covid-19 epidemic represents a special risk for kidney patients due to their comorbidities and advanced age, and the need for hemodialysis treatment in group rooms. it also represents a risk for professionals responsible for their attention. this manuscript contains a proposal for action to prevent infection of professionals in the nephrology services, one of the most valuable assets at the present time. in addition to the obvious need to protect patients, it is no less important to guarantee the protection of the healthcare professionals who have to treat them. there are a number of reasons why the protection of healthcare professionals has to be one of the main objectives in the sars-cov-2 pandemic: 1) they are necessary to guarantee the continuity of care; 2) they have a high risk of contagion due to their front-line exposure to infected patients; and 3) they may act as transmission vehicles in their day-to-day work to patients, other colleagues, and members of their families and the community. up to 25 february 2020, china had reported 3387 infected healthcare workers in hubei alone, at least 18 of whom died as a result of the infection. 1 in spain, according to the most recent official data made public by the ministry of health, on 7 may there were 35,548 healthcare professionals infected by covid-19. 2 spain has one of the highest figures in the world for healthcare workers infected by covid19 . in a recent study in a hospital in madrid, 20% of the healthcare staff in the nephrology department were diagnosed with covid-19. 3 like other viruses of the same family, sars-cov-2 spreads mainly through droplets and direct contact with the secretions of infected people. 4 however, it also has several distinguishing features which make it necessary to increase precautions against contagion, including the high rate of infected individuals who remain asymptomatic with an incubation period which can be as long as 24 days 5 , the hyper-affinity to the receptors of angiotensin-converting enzyme 2 (ace2), which makes it highly transmissible 6, 7 , and the 20-30% falsenegative rate in pcr detection. 8 every hospital, nephrology department and haemodialysis centre has implemented its own action protocol, the majority aimed at preventing transmission to patients. [9] [10] [11] there has also been special emphasis on preventing transmission from patients to healthcare professionals. [12] [13] [14] [15] however, less attention has been paid to preventing contagion among healthcare professionals within the hospital setting, particularly when, as already mentioned, the infection can be asymptomatic for a prolonged period, and the available detection tools fail to detect all cases. in the present manuscript we present a set of strategies designed to prevent contagion among healthcare professionals in a nephrology department through patients and the co-workers themselves. healthcare professionals are at risk due to the activities they perform. this exposure can result from contact with other patients or with co-workers. there are different types of exposure to sars-cov-2, and each type can have different consequences 13 : a) low-risk exposure without the appropriate protective equipment: isolated episodes of exposure of < 15 min with minimal physical contact; for example, delivering medi-cation or a food tray, taking vital signs, procedures that do not generate aerosols, contact with cases of healthcare professionals in the work environment. b) high-risk exposure without the appropriate protective equipment: contact with a household member or contact with an exposure time of more than 15 min at a distance of less than 2 m, contact with a patient at high risk of exposure to respiratory secretions without protection or procedures that generate aerosols. in the first case, if they are asymptomatic, the healthcare professional can continue working with a surgical mask throughout their working day, although they should monitor their temperature and be alert to symptoms. should they develop symptoms, they should self-isolate immediately (separate themselves from other individuals) and notify occupational health without delay. in the second case, the healthcare professional should be sent home with axillary temperature monitoring twice a day, and withdrawn from healthcare activity for seven days. they may return to work on day eight if they are still asymptomatic. they will need to wear a surgical mask throughout their working day until day 14 after the contact (in addition to the usual basic self-protection measures). the department designated as responsible by the hospital (occupational health, occupational risk prevention or preventive medicine) will carry out a personalised risk assessment, taking into account the type of exposure and the department in which the member of staff works, and may give instructions adapted to the specific case. healthcare workers are forced to accept the possibility of being exposed to and infected by sars-cov-2 15,16 as they have to work in close proximity to suspected patients or cases and, additionally, have to cope with an exceptional workload. in these conditions, it is particularly important for all workers to know what personal protective equipment should be used for each activity, and to be conversant with the procedure for putting on and removing said equipment. 17 adherence to these measures should be promoted and supervised by teamwork among the medical-nursing-auxiliary staff, reinforcing both actions. 3, 18 like any healthcare professional in any healthcare facility, nephrology staff should adhere to the following 17,18 : none-compulsory wearing of masks in common spaces (stairs, hallways, elevators, lifts, corridors, terraces, toilets and reception areas); none-use the stairs instead of the lift, whenever possible; none-in corridors and stairs, always keep to the right; none-systematically wash hands with soap and water or apply alcohol solutions to hands; none-keep a safe distance (at least 2 m); noneavoid touching their eyes, nose and mouth with unwashed hands; none-cover their nose and mouth with their sleeve or a tissue and then dispose of it if they cough or sneeze; none-avoid sharing personal equipment and devices with other workers; none-avoid face-to-face meetings, preferably using videoconferences or other non-face-to-face systems; none-clean and disinfect workspaces and frequently touched surfaces, such as keyboards, dictation devices or land-line telephones, and personal items, such as stethoscopes or mobile phones. sars-cov-2 is capable of living on surfaces for hours or days 19, 20 , but it is easily eliminated with common disinfectants such as sodium hypochlorite at 1000 ppm or products proven to be virucidal (h100, h200, etc.); none-facilitate the tasks of cleaning and disinfection staff, leaving the workspace as free as possible. a frequent cleaning and disinfection strategy is necessary for common areas: light switches, countertops, chair arms, stair railings, lift buttons, door knobs, etc. 21 ; none-immediately report any respiratory symptoms or lowgrade fever if they have had close contact (less than 2 m) with a probable or confirmed case; none-stay home when they are unwell, notifying the centre by telephone and following the protocol indicated by their centre. one of the first measures taken by the spanish ministry of health, before decreeing the state of national alarm and the confinement of the entire population 22 , was to recommend that the autonomous regions not organise congresses, workshops, seminars or training courses for healthcare professionals, other than routine events within their own services, in order to guarantee the availability of this group in their usual care-provision services and prevent them from acting as transmitters of the disease to the most vulnerable population groups 23 . high-risk contacts (close contact with a probable/confirmed case without personal protective equipment) among healthcare professionals can also occur during normal activity in the workplace, between individuals from the same team, who are apparently healthy and asymptomatic 24 and are not aware of having been exposed to the virus. in a hospital in taipei, 17 healthcare professionals were infected by sars despite not coming into direct contact with infected patients, and virus rna was detected on surfaces incleanäreas. 25 the consequences of this type of transmission are a large number of people from the same department being on sick leave, and the ensuing problems in guaranteeing healthcare provision. the restrictions regarding gatherings of people that apply to the general population must also be applied at the hospital/service/centre level, especially when they are dealing with an at-risk population, as mentioned above. the measures to be adopted entail a change in customs adapted to the situation, and a high degree of commitment from the centre. strategies aimed at protecting healthcare professionals include 12, 25 : none-restricting the number of healthcare professionals who access the facilities and limiting the total number of staff dedicated to patient care; none-encouraging healthcare personnel to remain within the hospital only the time essential for carrying out their care provision tasks; none-promoting teleworking by facilitating remote access to the hospital's medical records, which will avoid putting patients and healthcare professionals at risk, and allow them to work from home; none-suspending department clinical sessions and face-toface hand-over sessions for shift changes for which modern communication tools can be used, such as free videoconferences that enable several people to connect from different places (zoom, skype, microsoft teams, etc.); none-in areas where the work is carried out by several people (residents and assistants), distributing the patients to avoid more than one person attending to each patient, and having discussions and information sharing via whatsapp or by telephone; none-if possible, working in separate offices. if more than one person share an office, they should be more than 2 m apart; whenever possible, the space should be kept well ventilated; none-avoiding busy places in the hospital (cafeteria) and not having meals or breaks together or using the lifts if safe distancing cannot be maintained. healthcare personnel who treat kidney patients carry out specific activities with varying degrees of complexity which require different protective measures, depending on the need for asepsis or the risk of splashing and presence of aerosols. these measures and the protective equipment necessary in each case are summarised in table 1 . [26] [27] [28] [29] [30] [31] a special care or protective measures for medical, nursing and auxiliary staff who work daily with haemodialysis patients as has previously been described in other publications 3,10 , the main protection measures for healthcare professionals and patients in haemodialysis units are: 1) adequate information for patients attending the centre in terms of maintaining a safe distance from fellow patients in waiting rooms and ambulances, and in the use of surgical masks and frequent hand washing; 2) early detection of patients suspected to be infected on arrival at the unit (questionnaires about symptoms or close contacts, taking temperature), and if highly suspect, taking a nasopharyngeal swab for pcr testing. protective equipment varies depending on the unit's policy regarding patient screening for covid-19: 3 this equipment includes a heavy-duty surgical gown, waterproof apron, cap, ffp2 mask with a surgical mask over it to protect it from external contamination and prevent droplet transmission by the healthcare professional if the ffp2 has a filter 3,10 , double gloves (one long pair over the gown and other short), and googles or face shield, with a protocol for putting on and taking off the ppe to avoid contamination which includes changing gloves between patients, with alcohol-solution hygiene before and after the change 3,18 . none-in units where the population cared for is screened and patients are known to be negative, the use of a surgical mask and gloves is sufficient, but with the addition of a waterproof gown or a heavy-duty surgical gown with a waterproof apron and protective screen for the connection and disconnection of, and care of patients with lines. gowns and gloves should be changed between patients. the same isolation gown should not be used for the care of more than one patient, except if they are isolated together (isolation of cohorts) with adequate hand washing after removal of both and before attending to the next patient (table 1) . bedside visits to the haemodialysis patient, whether in the hospital or a peripheral centre, should only be made by one doctor at a time. each doctor should always see the same patients, unless they require help from another colleague for the assessment, in which case they should see the patient separately. nursing staff should also always attend to the same patients, to make it easier to trace exposed workers. it is important that staffing levels be adjusted to cover the added difficulty of caring for patients infected with covid-19. one direct care nurse has been recommended for every 3-4 patients, and one nurse for every 7-8 patients, who acts as ä mirrorḧelping with medication, preparation of material, management of medical records, etc., and one nursing assistant every 5-7 patients who also acts as amirror. 3 at the end of the shift, deep cleaning of surfaces, monitors, floors and walls should be carried out in the unit. devices such as pulse oximeters, thermometers and sphygmomanometers should be cleaned between patients with virucidal substances or sodium hypochlorite, with this measure being applied in all work areas. 19, 20 of particular interest in the prevention of transmission to patients and healthcare workers is the reincorporation into the units of patients who have been infected by covid in isolation areas. after seven days free of symptoms, the recommendation is to repeat the pcr test with an interval of 48 h and, if both are negative, incorporate them normally with the rest of the patients. 32 b special care or protection measures for staff working in peritoneal dialysis (training, etc.) specialised diagnosis and treatment related to peritoneal dialysis and its complications should be provided by the nephrologist via phone, whatsapp or the internet. assessments should be carried out to exclude the presence of suspected or probable covid-19 among patients and caregivers. during admission, to minimise the risk of infection, the recommendation is to substitute automated peritoneal dialysis (apd) for continuous ambulatory peritoneal dialysis (capd), reducing the number of connections and exchanges, and thus reducing the possibility of contact infection. if the patient's medical condition is such that they cannot self-administer the dialysis, they will be put on haemodialysis while in hospital. 33 any surfaces, supplies or equipment located in rooms where suspect patients have been dialysed should be disinfected or discarded. for training, the nurse should use the individual protection equipment described in table 1 (surgical mask with a face shield on top, gloves and a waterproof gown or a heavy-duty surgical gown with a waterproof apron). the patient should wear a surgical mask and gloves and their companion should also wear personal protective equipment similar to that of the nursing staff. the same precautions already described should be taken after removal of the protective equipment, with suitable hand hygiene before and after. before admission to hospital, patients will be examined to assess their risk of exposure to covid-19 and the presence of symptoms, including a nasopharyngeal swab and pcr test, so that they can be appropriately placed within the assigned admission areas (covid ward, suspect ward or negative ward). as long as the number of patients with covid-19 is high, it is advisable to group them together in confined wards to limit the number of exposed healthcare staff and conserve supplies. in these covid-19 wards, the staff should wear individual protective equipment and will not need to change it between patients (isolation of cohorts). on negative hospital wards (negative pcr on admission), although the risk is low, as preventive measures during the covid-19 epidemic, gloves and a surgical mask should be worn to enter the room, unless there is a risk of aerosols, when a ffp2 mask should be worn covered with a disposable surgical mask and, provided there is no risk of splashing, a disposable conventional gown. if there is a risk of splashing, a face shield or goggles should be worn and a waterproof apron should be placed over the gown, which should be discarded at the end of the visit. hand hygiene should be performed before and after the provision of care to each of the patients. the protective measures should be adapted to the type of activity to be carried out (table 1) . before leaving the room, the ppe (gloves, screen and gown) should be removed, taking special care to avoid touching the outer surfaces of the gloves and gown. these items should be left inside the room in a place specifically provided for that purpose; staff should never go out into the corridor with gloves or a gown. after removing the protective equipment, they should wash their hands. in the case of hospitalised patients, healthcare staff should spend the minimum time possible in the room. only those who need attention and require an examination should be approached, and this should be done with the ppe described. bedside visits to hospitalised patients should only be performed by one doctor at a time. each doctor should always see the same patients, unless they require help from another colleague for the assessment, in which case they should see the patient separately. while the pandemic continues, face-to-face patient consultations in nephrology clinics, whatever the type (transplant, waiting list, clinical nephrology, ckd), should as far as possible be kept to a minimum. it is imperative for telemedicine to help close the gap created by the pandemic and extend our reach in the future, and for that reason it is already being widely applied, including in a number of surgical specialities. 34, 35 for patients with stable kidney function, lengthening the interval between outpatient visits is recommended to avoid patient visits to the hospital. in addition to giving preference to telephone and telematic care, strategies for coordination with primary care should be developed, promoting health centres having their healthcare staff carry out analyses at home. as in all areas, measures will be carried out aimed at the early identification of suspected infection among patients (questionnaires about symptoms or close contacts, taking temperature) and, if suspected, a pcr nasopharyngeal swab test will be carried out. if there is no alternative to a face-to-face consultation in the outpatient clinic, the visit should be held as quickly as possible and, if necessary, continued by telephone. patients to be seen in the clinic should arrive at staggered times with minimum waiting time, ensuring that there is only one doctor and one patient in each consultation, maintaining a distance of more than 2 m between them. a family member should only enter if absolutely necessary. face-to-face consultation in the clinic is considered a low-risk activity, so the use of a surgical mask is sufficient, both by the patient and the healthcare professional. if contact with the patient is necessary, gloves should be worn, with suitable hand hygiene both before and after. similarly, strict measures for cleaning and disinfection of the consulting room and surfaces must be applied, the central air conditioning should be turned off and good ventilation maintained. 36 in patients who require invasive procedures, such as kidney biopsy or catheter placement, a sars-cov-2 pcr test should be determined 24 h before the procedure, in order to appropriately allocate positive patients to a specially dedicated operating theatre. as shown in table 1 , biopsies and catheter placement are considered activities requiring sterile condi-tions where there is a risk of splashing, so the equipment to be used should include sterile gloves and gown, in addition to the other protection already mentioned. healthcare workers' need for protection in this pandemic is not limited exclusively to their exposure to transmission. in a study of 994 healthcare professionals in the province of wuhan, almost 40% developed psychological disorders immediately after the epidemic. these disorders mainly involved anxiety, which required different types of psychological support and mainly affected young women. 37 although the fear of self-infection is accepted by most healthcare professionals, many express concern about being vehicles of transmission to their own families, especially to family members who are older, immunocompromised or have chronic diseases. 18 moreover, carrying out haemodialysis on infected patients involves added factors, such as prolonged exposure for a number of hours, alone and wearing protective equipment, all elements which can increase the state of anxiety. these findings highlight the importance of being prepared to support frontline workers through mental health interventions in times of widespread crisis. 38 • self-protection is the responsibility of all staff providing care for people with kidney disease. • contact between healthcare professionals is a risk factor for nosocomial transmission in hospitals and health centres. modifying the way we interrelate with each other is a priority if we are to stop the spread of the virus and guarantee healthcare to all those who need it, not only in our speciality but in the hospital as a whole. • strict compliance with standard, droplet and contact precautions with adequate protection is the responsibility of healthcare personnel providing care for suspected or diagnosed cases of covid-19. • meeting the emotional and psychological needs of healthcare personnel is essential in crisis situations such as the current pandemic. the authors declare that they have no conflicts of interest. r e f e r e n c e s doctors and nurses fighting coronavirus in china die of both infection and fatigue situación de covid-19 en españa a 7 de mayo de 2020 aprendiendo día a día el primer mes de pandemia de covid19 covid-19 coronavirus pandemic clinical features of patients infected with 2019 novel coronavirus in wuhan tissue distribution of ace2 protein, the functional receptor for sars coronavirus. a first step in understanding sars pathogenesis ace2: from vasopeptidase to sars virus receptor false-negative results of real-time reverse-transcriptase polymerase chain reaction for severe acute respiratory syndrome coronavirus 2: role of deep-learning-based ct diagnosis and insights from two cases management of the sars-cov-2 (covid 19) coronavirus epidemic in hemodialysis units [manejo de la epidemia por coronavirus sars-cov-2 (covid 19) en unidades de hemodiálisis covid-19 and dialysis units: what do we know now and what should we do? centro de coordinación de alertas y emergencias sanitarias. dirección general de salud pública guía de actuación con los profesionales sanitarios en el caso de exposiciones de riesgo a covid-19 en el ámbito sanitario. centro de coordinación de alertas y emergencias sanitarias. dirección general de salud pública novel coronavirus (2019-ncov) technical guidance taiwan's traffic control bundle and the elimination of nosocomial severe acute respiratory syndrome among health care workers controlling mers: lesson learned from sars how to train the health personnel for protecting themselves from novel coronavirus (covid-19) infection during their patient or suspected case care supporting the health care workforce during the covid-19 global epidemic surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient interim infection prevention and control recommendations for patients with confirmed coronavirus disease 2019 (covid-19) or persons under investigation for covid-19 in healthcare settings relaciones con las cortes y memoria democrática recomendaciones de medidas extraordinarias en relación con la situación provocada por el nuevo coronavirus covid-19 destinadas a consejeros de sanidad de comunidades autónomas presumed asymptomatic carrier transmission of covid-19 how should u.s. hospitals prepare for coronavirus disease 2019 (covid-19)? report of the who-china joint mission on coronavirus disease effectiveness of n95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis of-masks-in-the-community-during-home-care-and-inhealth care-settings-in-the health care infection prevention and control faqs for covid-19 aerosol generating procedures and risk of transmission of acute respiratory infections to health care workers: a systematic review infectious diseases society of america guidelines on infection prevention for health care personnel caring for patients with suspected or known covid-19 de-isolation of covid-positive haemodialysis patients in the outpatient setting: a single centre experience recommendations for prevention and management of covid-19 in peritoneal dialysis patients telehealth utilization in response to the novel coronavirus (covid-19) pandemic in orthopaedic surgery implementation guide for rapid integration of an outpatient telemedicine program during the covid-19 pandemic strategies for prevention and control of the 2019 novel coronavirus disease in the department of kidney transplantation impact on mental health and perceptions of psychological care among medical and nursing staff in wuhan during the 2019 novel coronavirus disease outbreak: a cross-sectional study protecting health care workers during the covid-19 coronavirus outbreak -lessons from taiwan's sars response key: cord-344729-sjjedgws authors: bhaskar, sonu; sharma, divyansh; walker, antony h.; mcdonald, mark; huasen, bella; haridas, abilash; mahata, manoj kumar; jabbour, pascal title: acute neurological care in the covid-19 era: the pandemic health system resilience program (reprogram) consortium pathway date: 2020-05-29 journal: front neurol doi: 10.3389/fneur.2020.00579 sha: doc_id: 344729 cord_uid: sjjedgws the management of acute neurological conditions, particularly acute ischemic stroke, in the context of coronavirus disease 2019 (covid-19), is of importance, considering the risk of infection to the healthcare workers and patients and emerging evidence of the neuroinvasive potential of the virus. there are variations in expert guidelines further complicating the picture for clinicians in acute settings. in this light, there is a compelling need for further formulation of recommendations that compile these variations seen in the numerous guidelines present. health system protocols for managing ongoing acute neurological care and intervention need consideration of safety and well-being of the frontline healthcare workers and the patients. we examine existing pathways and their efficacy to mitigate viral exposure to the healthcare workers and patients and synthesize a systemic approach to manage patients with acute neurological conditions in the covid-19 scenario. early experiences with a covid-19 positive stroke patient treated with endovascular thrombectomy is presented to highlight the urgent need for adequate personal protective equipment (ppe) during acute neuro-interventional procedures. neurotropism is a well-known feature of beta-coronaviruses, of which severe acute respiratory syndrome coronavirus 2 (sars-cov-2), the virus which causes coronavirus disease 2019 (covid-19) (1), is one, with effects on the brain stem, and in particular, the cardiorespiratory center thought to result in breathing dysfunction (2) . the italian experience has displayed the presence of neurological symptoms in covid-19 positive patients (3) . the chinese study from wuhan published in jama neurology reported neurological manifestations in a significant proportion (36.4%) of patients with covid-19 (4) . recent findings surrounding anosmia as an early symptom of covid19 have invoked further interest in this hypothesis (5) . the role of the central component in hyposmia could also be suspected. those presenting with symptoms of skeletal muscle damage are at higher risk of liver and kidney damage. it is evident that the virus is able to cross the blood-brain barrier (bbb), which is postulated to occur post-infection due to interactions with the angiotensin-converting enzyme 2 (ace2) receptor present at various sites within the cerebral circulation (6) . another case report on a female airline worker with covid-19 positive status developing acute necrotizing hemorrhagic encephalopathy (7), a condition that is typically seen following cytokine storm in influenza, suggests possible bbb compromise. independent of possible neurotropism, covid-19 infection is associated with coagulopathy (elevated d-dimer and severe platelet reduction) and may disrupt blood pressure regulation through interaction with the ace2 receptor. covid-19 could possibly contribute to ischemic and hemorrhagic stroke aside from neurotropism (8) . taken together these anecdotal reports suggest a possible neuroinvasive potential of the virus. management of patients with acute ischemic stroke during covid-19 pandemic could be challenging and certain precautions must be taken in order to protect healthcare workers, particularly in the delivery of endovascular treatment, where aerosol could be produced during the procedures, to prevent further vector transmission (9) . as a result of this, various modifications of the traditional code stroke are being discussed amongst hospitals, and in particular, khosravani et al. (10) propose the concept of the "protected code stroke" whereby management of patients with a suspected stroke is modified in the context of the covid-19 pandemic to protect healthcare workers. a conservative approach involving fever screening, history taking to rule out covid-19 risks and the presence of infectious symptoms could replace routine "code stroke." minimizing healthcare workers in the same room as the patient, specifications surrounding personal protective equipment use, and the delegation of specific roles to limit the risk of infection have been suggested. however, this protocol is not ratified by other major associations and does not consider the surgical aspects associated with endovascular treatment, a major gap that must be addressed. various bodies have put forth guidelines into how surgery should be conducted in these times to minimize harm to patients and healthcare workers alike. however, they are non-specific to endovascular treatment. nonetheless, general intercollegiate surgical guidelines (11) are available, and emphasize the importance of not undertaking procedures that may result in poorly controlled aerosol production, minimization of theater staff, team changes required during a prolonged surgery, and intubation and extubation within the operation theater itself, with only necessary staff members present. this differs from the "society of american gastrointestinal and endoscopic surgeons and the european association of endoscopic surgery recommendations regarding surgical response to covid-19 crisis (12), " which recommend that "unless there is an emergency, there should be no exchange of room staff." notably, neither of these guidelines are specific to endovascular treatment. the society of neurointerventional surgery recently released "recommendations for the care of emergent neuro-interventional patients in the setting of covid-19 (13) , " which consider the management of patients before, during and after thrombectomy. they agree with the model proposed by khosravani et al. (10) with regards to presuming covid positive status unless proven otherwise. notably, these guidelines concur with the "consensus statement from society for neuroscience in anesthesiology & critical care" about "anesthetic management of endovascular treatment of acute ischemic stroke during covid-19 pandemic (9), " in that general anesthesia should be used if there are concerns surrounding the need for mid-procedural conversion and intubation which could be very detrimental and could expose the whole team, a scenario that should be avoided at all cost. however, these latter guidelines do not address the issue of separating covid-19 patients from others in terms of scanning equipment, radiology suites, and decontamination protocols. given the possible neuroinvasive potential of covid-19, there is a need to consider both the short and long-term implications of covid-19, and implement systems-level methods of assessing, addressing, and longer-term monitoring (figure 1 ). we expect that there is a significant amount of variability based on institution and country with respect to covid-19 testing. for example, the earliest possible result time for covid testing at one of our hospitals is 7 h but the serology test that would take minutes to give a result was just food and drug administration (fda) approved and hopefully will be introduced soon but until this is available widely it will be practically difficult to rule out covid-19 during code stroke (at least at many hospitals in the us and elsewhere), and as such, we propose that all patients undergoing code stroke be presumed covid-19 positive. this is concurrent with the american heart association (aha) emergency guidelines for stroke centers in the context of covid-19 (14) . all covid-19 positive patients should be triaged into covid-19 neuro or covid-19 non-neuro wards depending upon the presence of neurological symptoms (6) . common neurological complaints include dizziness, headache, anosmia, and dysgeusia (14) . in patients with a suspected acute stroke: • all acute stroke patients should be treated as covid positive until proven otherwise, and full personal protective equipment (ppe) should be used when responding to a code stroke (10, 13) . • telemedicine should be used to determine eligibility and perform intravenous thrombolysis [trans plasminogen activator (tpa)] to minimize potential exposure to infectious patients (14, 15) . patients who receive tpa do not need to be admitted to the icu, if stable. prior to the pandemic, it was standard practice in the us to admit all post-tpa patients to the icu for 24 h. however, the aha recommends that there is little evidence to support post-tpa icu stay (14) . • separate scanning equipment and radiology suites for negative, suspected, and confirmed covid-19 patients, with clear decontamination protocols after each patient (16) . • separate suites for endovascular treatment of negative and suspected/confirmed covid-19 patients, with extra equipment stocked in the latter to prevent staff having to retrieve equipment. clear decontamination protocols after each patient (13) . • in all theaters, minimize exposure to staff and the number of perioperative workers (10, 11) . • in the case of long procedures, team changes should be encouraged to minimize prolonged exposure to healthcare workers (11) . • a lowered threshold for general anesthesia administration in terms of concerns surrounding the need for mid-procedural conversion (9, 13). • where possible, post thrombectomy recovery should occur outside of icu in the stroke unit if those beds are required for covid-19 patients (14). • it is recommended that suspected covid-19 patients should be treated as covid-19 positive until the polymerase chain reaction (pcr) diagnosis confirms otherwise, and such patients should be admitted to covid-19 positive wards. separate stroke units for covid-19 positive and negative patients are recommended. • to ensure the quality of stroke care for covid-19 stroke patients, such patients could be admitted to other wards for covid-19 positive patients. dysphagia management, physical or logo therapy, and standard in-hospital rehabilitation of stroke patients should be provided; however, concerned staff should wear adequate ppe to prevent exposure and transmission. • healthcare workers in secondary hospitals and radiology facilities are recommended to wear adequate ppes when caring for someone with a confirmed or suspected case of covid-19. it is advised that patients in which neurological symptoms are present: • patients should be monitored for short-term and/or possibly long term cognitive or neurological impairments. cognitive impairment could be assessed using routine tests such as mini-mental state examination (mmse) by treating clinicians. large scale community screening with good sensitivity/specificity could also be administered using telephone, by informant proxy or directly by post [such as cognitive assessment screening test (cast)] provided the test has a good sensitivity/specificity balance (>85%) (17) . • for patients presenting with neurological symptoms in future, past covid-19 infection should be ascertained, along with the clinical severity, and corroborating imaging findings. • in addition, imaging could be used to assess the damage to the blood brain barrier (bbb) to examine whether covid-19 induces a transient or long-term change. bbb assessment and permeability quantification could be done either: (a) semi-quantitatively by comparing the scans before and after contrast injection, or (b) quantitatively using perfusionweighted or permeability magnetic resonance imaging (mri) technique, vis a vis dynamic contrast-enhanced mri (dce-mri) (18) . for all acute neurological conditions, a major concern revolves around the decrease in the proportion of acute presentations due to fear of contracting covid-19 while accessing health services and the presumption that all healthcare resources are now mobilized to prioritize covid-19 patients (14). this could have negative consequences vis a vis long-term disability subsequent to permanent brain damage due to acute neurological emergencies such as traumatic brain injury (19) . similarly, earlier symptoms of emergent brain tumors, such as headache and ataxia (20) may be neglected or cranial neuropathies from mass effect of a brain aneurysm, due to the perceived cons of seeking help. as of yet, significant gaps exist in the literature pertaining to how to address delayed or absence of presentation. use of telemedicine where possible, social distancing within clinics for patients coming to the hospitals and systems-level separation of patients with fever and respiratory symptoms from those without having been proposed as possible solutions to minimize the impact (21) . public health campaigns surrounding measures that are in place to minimize infection transmission and ill consequences of failing to present with a condition that does indeed warrant medical attention need to be pursued. also, the longterm negative impact of the delayed presentation should be emphasized. a recent case report identified a link between frequent convulsive seizures and covid-19 infection in the context of emergent epilepsy (22) . in light of these anecdotal findings, it is relevant that guidelines pertaining to seizure management in covid-19 cases are not available, to the best of our knowledge. with regards to chronic epilepsy patients, longer-term medicine prescription, use of telemedicine, and optimal seizure management plans have been recommended (23) . similar issues exist with respect to the management of aneurysmal presentations as no specific guidelines exist in the covid-19 scenario. the number of covid 19 positive patients under 18 years of age represent 1.7% of total lab-confirmed cases in the usa (24) . given the relatively low proportion of covid-19 pediatric patients, neurological manifestations are very unlikely to be delineated. this pandemic is adversely challenging the health systems, causing stress, fear to healthcare workers, with the pressures of lengthened hours, lack of ppe equipment and systemic changes that are having to be implemented to protect them (10, 14) . indeed many healthcare workers have expressed publicly in the media and on social media channels that the risk of infecting their families is a source of constant stress to them and impacting their intimate relationships significantly (25) . indeed it is also overlooked that the scarcity of resources can impact the management of patients and potentially result in some patient who may have ordinarily fared better having worse outcomes, another key factor in terms of mental health issues and also indeed the morale of healthcare workers, which can have longer terms impacts in terms of the efficiency and drive of health systems (26) . considering public health ethics, and more specifically the concept of utilitarianism which forms a key part of this, the need to protect our frontline healthcare workers and support their health becomes evident. utilitarianism refers to judging actions based on how much good they will do for the greatest number of people -thereby forming the backbone of ethics and health policy debate underpinning the crisis (27) . protecting our healthcare workers gives the most benefit. this can, therefore, involve protecting them from contracting the infection, which could then be spread to their families, other patients, and resultantly the community, as well as focusing on their psychological health so they are able to discharge their duties efficiently and effectively. various strategies have been proposed for addressing these issues. it is pivotal that any changes to protocols, such as those related to changes in how to carry out code stroke actions are wellrehearsed, which may include simulation training with the revised protocol (10) . an extra healthcare worker on the team will be needed to observe the team while at work to try to detect any breach in the covid-19 precaution protocols and at the end of a procedure to help undress the team and clean their ppes. managing a pandemic of this proportion can undeniably cause stress and fear. as such it has been proposed that healthcare workers, particularly those working with covid-19 positive cases, be given regular breaks (16) and encouraged to recognize their limits (28) . we also propose that healthcare workers be given information pertaining to relaxation and coping strategies; whilst many healthcare workers may already be aware of these, a reminder may be beneficial. the world health organization "mental health and psychosocial considerations during the covid-19 outbreak" document advocates the role of a "buddy" or peer support system for more experienced clinicians to assist and support their less experienced colleagues, as a means to not only help manage stress but also learn how to efficiently enact the protocols that may be in place in an organization (29) . this is especially relevant as the health systems are being reorganized and protocols are being revised regularly, sometimes on a daily basis (30) . online peer-support networks for discussions as well as social media and messaging chat groups may provide a valuable outlet for clinicians. planning how healthcare workers will interact with their families and reorganize their living arrangements can help de-escalate the stressors as reported in the media (25) . the victorian government in australia has announced that all healthcare workers required to self-isolate or tested positive for covid-19 will be provided hotel accommodation to minimize risks to them and to their families, with an indication to expand this model to other states and territories (31) . it is important for these recommendations to be specific to avoid creating further anxiety among healthcare workers (32) . in the covid-19 pandemic, acute neurological care is increasingly under stress due to ongoing reorganization and rationing of services to meet the demands of frontline covid-19 cases. in this article, we have identified and proposed various considerations that may minimize the risk to health systems, healthcare workers, and the patients. the differential diagnosis of severe acute respiratory syndrome cov (sars-cov2) infection should be considered in patients with neurological symptoms during the covid-19 period (4). this is important to avoid missed or delayed diagnosis and prevent viral transmission. all patients amidst this pandemic should be screened for covid-19 and telemedicine could be used to triage these patients and possibly deliver intravenous thrombolysis. for those who may be candidates for endovascular thrombectomy, extra precautions need to be taken to minimize procedural risks associated with the aerosol transmission of the covid-19 virus and possible exposure to the healthcare staff. an example of reperfusion therapy work-up with ppes in a covid-19 stroke patient is illustrated in figure 2 . public health campaigns to educate and increase awareness of the community about the need to seek urgent medical attention should acute neurological symptoms occur. special considerations also apply for patients with traumatic brain injury and those requiring urgent aneurysm surgery or carotid endarterectomy. we are alarmed at the rising deaths of healthcare workers who are waging a war against the covid-19 without the provision of adequate ppe to defend themselves. the cost of adopting the proposed protocol and its impact on the quality of care merits further study. the current consortium is expeditiously working toward rapid adoption of the proposed protocol. further study on the impact and cost these measures may have on the quality of care and its results are envisaged. however, given the nature of the pandemic and emerging situation, the safety of healthcare workers' is paramount and thus justifies the heightened safety measures suggested in our protocol with an anticipation that this would hopefully limit the exposure. minimizing the harm to healthcare workers should be a priority as potential exposure can not only compromise the health systems, expose other workers, and patients to covid-19; but will also have a negative impact on the morale of professional colleagues. written, informed consent was obtained from the individual/legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article. sb devised the project, the main conceptual ideas and proof outline, encouraged ds to investigate and supervised the findings of this work. sb and ds wrote the first draft of the manuscript. all authors discussed the results and recommendations and contributed to the final manuscript. the consortium would like to thank pj for sharing an illustrative case example included in the study. the opinions expressed in this article are those of the authors and do not necessarily represent the decisions, official policy, or opinions of the affiliated institutions. we would like to acknowledge the reprogram consortium members who have worked tirelessly over the last days in contributing to various guidelines, recommendations, policy briefs, and ongoing discussions during these unprecedented and challenging times despite the incredibly short timeframe. we would like to dedicate this work to our healthcare workers who have died due to covid-19 while serving the patients at the frontline and to those who continue to serve during these challenging times despite lack of personal protective equipment. naming the coronavirus disease (covid-19) and the virus that causes it the neuroinvasive potential of sars-cov2 may play a role in the respiratory failure of covid-19 patients available online at neurologic manifestations of hospitalized patients with coronavirus disease loss of sense of smell as marker of covid-19 infection evidence of the covid-19 virus targeting the cns: tissue distribution, hostvirus interaction, and proposed neurotropic mechanisms covid-19-associated acute hemorrhagic necrotizing encephalopathy: ct and mri features nervous system involvement after infection with covid-19 and other coronaviruses anesthetic management of endovascular treatment of acute ischemic stroke during covid-19 pandemic: consensus statement from society for neuroscience in anesthesiology & critical care (snacc)_endorsed by society of vascular & interventional neurology (svin), society of neurointerventional surgery (snis), neurocritical care society (ncs), and european society of minimally invasive neurological therapy (esmint) protected code stroke: hyperacute stroke management during the coronavirus disease 2019 (covid-19) pandemic. stroke updated intercollegiate general surgery guidance on covid-19. 35-43 lincoln's inn fields society of american gastrointestinal and endoscopic surgeons and the european association of endoscopic surgery. sages and eaes recommendations regarding surgical response to covid-19 crisis society of neurointerventional surgery recommendations for the care of emergent neurointerventional patients in the setting of covid-19 temporary emergency guidance to us stroke centers during the covid-19 pandemic letter: the coronavirus disease 2019 global pandemic: a neurosurgical treatment algorithm the battle against coronavirus disease 2019 (covid-19): emergency management and infection control in a radiology department a review of screening tests for cognitive impairment quantitative imaging assessment of blood-brain barrier permeability in humans evaluation of the disability determination process for traumatic brain injury in veterans signs and symptoms of patients with brain tumors presenting to the emergency department headache clinic workflows during the covid-19 pandemic frequent convulsive seizures in an adult patient with covid-19: a case report covid-19 resources for epilepsy clinicians cdc covid-19 response team. coronavirus disease 2019 in children -united states risk of infecting others with covid-19 key concern for healthcare workers black dog institute. mental health ramifications of covid-19: sydney: the australian context black dog institute available online at mental health care for medical staff in china during the covid-19 outbreak world health organisation. mental health and psychosocial considerations during the covid-19 outbreak 2020 managing mental health challenges faced by healthcare workers during covid-19 pandemic healthcare workers to be given free accommodation under $20m 'hotels for heroes' plan supporting the health care workforce during the covid-19 global epidemic the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 bhaskar, sharma, walker, mcdonald, huasen, haridas, mahata and jabbour. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-347185-ttf8oigk authors: hart, andrew title: editorial covid-19 date: 2020-05-20 journal: j plast reconstr aesthet surg doi: 10.1016/j.bjps.2020.04.002 sha: doc_id: 347185 cord_uid: ttf8oigk nan jpras is a global journal, and that world changed on 9th january 2020 when the causative agent for a cluster of pneumonia cases of unknown origin in wuhan, hubei province, china was characterised as novel coronavirus disease 2019 (covid-19). recent weeks have seen covid-19 finally transform from a devastating regional epidemic into a true global pandemic. while 80% of cases are self-limiting, 14% merit inpatient care and ∼6% require intensive care. 1 at the time of writing, 3,664,143 individuals had become infected across 187 countries, and 257,303 were known to have succumbed; 2 this figure preceded its inevitable impact in the majority of low middle income countries and conflict/refugee zones across the globe. 3 with no signs or symptoms by which to unequivocally diagnose infective carriers, and without a universally available rapid diagnostic test, meaningful pharmacotherapy, or immunisation, 1 disease management falls to supportive care and public health measures. supportive care needs exceed any previous healthcare challenge, while public health measures are reliant on the blunt tools of isolation and travel restriction which have an economic impact on a scale not contemplated for generations (e.g. predicted 35% fall in u.k. gdpunemployment reaching 10%; 4 10% contraction in the eurozone economy, 42% fall in global oil price, 44% contraction in air & travel). 5 supply chains and whole sectors of industry will be disrupted, some never to re-establish themselves. food harvest or delivery may fail at a national scale. large scale civil unrest, collective violence, 6 mass migration, and loss of governance are real threats in both developed and developing countries if political leadership falters. governments have enforced robust but draconian restrictions on personal and societal freedoms to limit the rate of infection, softening the effect with financial support for support individuals, business sectors, and whole economies on a scale unmatched in history. resulting levels of government debt (e.g. u.k. 95% of gdp in 2020-21) 4 will burden a generation, and global recession will surely ensue. the insurance industries and taxable bases that support healthcare and bioscience research will inevitably contract, threatening longterm healthcare delivery, screening and preventive care systems, and the development of new therapies for the core conditions that plastic reconstructive & aesthetic surgeons treat. following utilitarian ethical principles, and facing massive deficits in acute care resources (such as inpatient beds, ventilators, intensive care provision, the staffing and consumables needed to run them, even oxygen) and protective equipment, hospital services around the world have had to stop the overwhelming majority of surgical care. no healthcare model has been robust enough to entirely avoid this, but socially funded models of equitable population care have arguably proved more robust and better supported by whole populations. the canniesburn unit reduced elective activity from six general anaesthetic theatres a day, to one list per week shared across all surgical specialties; this is typical for nhs services. all except the most immediately necessary and predictably beneficial cancer and elective surgery has stopped -a radical utilitarian rationing of healthcare resource that politicians had shied away from for generations was normalised inside a week. health and social care budgets, equally hot political potatoes, were also rationalised and the largest single injection of government funding in history was delivered within days. within a small number of days temporary 500-4000 bed covid-19 care "nightingale" hospitals were setup in sports stadia and national conference facilities across the u.k., and an army of staff recruited back into healthcare from career changes and early retirement. similar seismic changes have occurred around europe and the world, almost without comment. no longer can governments claim that healthcare is a private matter, or that fiscal prioritisation cannot rapidly support clinical priorities. covid-19 is not a surgical disease, but its impact upon surgical services has already been profound. in the short term, utilitarianism within the setting of nationally and globally limited resources, and the politics of a pandemic, meant a broad swathe of the care we delivered had to stop. ventilators, anaesthetic/sedative drugs, adrenaline, anaesthetists and nurses, icu beds, even things as simple as inpatient beds, masks and gowns, or oxygen, cannot be justifiably consumed when covid-19 patients might die within hours or colleagues become infected for the lack of them. we must recognise the workload pressure and psychological impact of this epidemic upon our colleagues in other specialties, and upon our nurses, allied healthcare professionals, and junior doctors. support for them must not only be in words and gestures, but by our limiting other workloads that may otherwise fall to them. that not only implies restricting who and what we treat but also how we treat those who cannot wait, in order to minimise operative duration, hospital stay, and risk of complications that could place critical additional stress onto other services. if the normal surgical care of cancers, trauma, and significantly painful or functionally restricting conditions must ethically pause, then surely aesthetic surgery cannot be justified. when healthcare colleagues are being placed at risk of severe disease or death through patient contact (particularly in the face of limited protective equipment or training), we must all support social measures to minimise case numbers -virtual clinical care systems should be used to enable patients not to travel. it's important that within the overall medical, and plastic surgical, community we hold to agreed common values, deferring to more acutely pressed colleagues, and build shared experience of the impact of the outbreak upon us. in the early phases of the outbreak that is simpler, as time passes it becomes harder to maintain and the risk of severe moral injury 7 , 8 becomes high if fault lines develop between specialties or individuals, and perceptions arise of winners and losers; those who fought vs. those who evaded the risk. the defining question of our generation must not become " and what did you lose during the covid outbreak?"; loss and risk should be shared as equally as possible. perception will count for as much, or more, than reality. if critical moral injury is sustained, then evidence from genocide, sectarian and military conflict indicates that hard-to-reconcile divisions will result, and those on both sides of the moral divide will suffer significant lasting harm. multidisciplinary working could not endure such division. as a profession we have become unused to placing ourselves at unrelenting risk of major harm due to the simple act of delivering patient care, yet data indicates that healthcare workers have greater than community average rates of infection, and are at significant risk of more severe disease. since the death of the first chinese doctor in wuhan, covid-19 has claimed the lives of a growing number of colleagues (those in the u.k. are currently remembered at https://www.bbc.co.uk/news/health-52242856 ). it is clear that certain specialties, procedures, and circumstances bring particular risk. staff with co-morbidities that place them at excessive risk if they were to contract covid-19 9 should be identified and shielded from frontline exposure, then enabled to support colleagues by delivering critically important supportive and managerial roles. patient flow and care pathways should be adjusted to minimise exposure risk (for staff benefit and to minimise crossinfection between patients), with increased utilisation of local anaesthesia, more conservative treatment options, and virtual clinics. risk of infection relates to contact proximity (logically this rises exponentially ∼2 metres distance until actual aerodigestive tract contact), duration of that proximity (particularly beyond 15 minutes), and the type of infective agent exposure -close prolonged contact with aerosolised aerodigestive tract secretions seems to carry highest risk. aerosol generation requires airflow across infected secretions -the higher the rate of flow and the more active the infection, the greater the viral load. high viral load seems to induce more severe disease, hence the tragic deaths of ent, emergency, and anaesthetic colleagues. plastic surgeons are therefore at greatest risk during functional / oncological oropharyngeal surgery, and tracheostomy, but logic dictates that any facial surgery places the operator at high risk of greater infective load. yet healthcare staff need not contract covid-19, and need not suffer severe disease or death, if they are simply enabled to work safely through organisation and institutional supply chain management. personal protective equipment (ppe) provision, and guidance on its use must recognise this. ppe needs should be appropriately risk stratifiedjust as we should not needlessly use this precious resource while colleagues in higher risk circumstances have failing supplies, there is a fundamental moral obligation upon governments and health agencies to deliver the right ppe, to the right staff, at the right time, in sufficient volume. professional bodies must accept their moral imperative to provide guidance on ppe that is evidence based, not supply based, and where evidence is not absolute they should err toward greater safety. bapras has recently issued professional guidance to aid specialty specific interpretation of government body and royal college guidelines on ppe use. 10 similarly, there is an onus upon us to minimise risk exposure for supporting staff, including minimising dressing clinic visits and operative durations -theatres should run with minimum staffing and training cases should not be undertaken. instead the most efficient available operator should accept the need to operate in person; juniors should not be left to field cases. the impact upon training and career progression will be workable in the short term, but if covid-19 related practice restrictions become protracted, then professional bodies will need to turn to web-based platforms to maintain education and training progression. this has begun, for example by the bssh, but broader scope arrangements will be needed and trainees pushed to use external resources rather than hands on training. this may lead to more efficient educational delivery in the longterm, if innovative virtual platform learning becomes normalised, and future courses and meeting cease their reliance on physical attendance. jpras strongly supports this direction, through promoting change from physical print copy to online access, soon through provision of journal clubs online, and through scoping novel platform use. a larger shift in technology will be needed to fully optimise remote learning, through immersive reality approaches. the short term clinical challenge is difficult, but the medium term will most probably be more so, and the long term may present existential threats to aspects of our specialty. unless the covid-19 peak, and its restrictions on practice, is of very short duration, fiscal compromise is inevitable and a sizeable waiting list of untreated or undiagnosed but urgent cases will amass. more advanced pathology may then need more complex care, and a growing number of cases (particularly hand trauma) will merit secondary reconstruction having been unable to access usual primary surgery. resource needs will be high. considerable logistical challenges will arise if services are to treat such cases timeously and avoid a prolonged hangover effect by failing to synchronously restore normal treatment times for the new cases that will still arise. the longterm will surely see a spike in all cause mortality as pathologies that went undiagnosed, or missed windows for early definitive treatment, run their course. that will likely be due not just to the malignancies we treat, but also to more subtle impacts upon overall health and fitness (e.g. fitness for prolonged general anaesthesia). if recession bites and unemployment rises as predicted, then socioeconomic deprivation will rise and safety standards in homes and workplaces become compromised, inevitably increasing the incidence and severity of pathologies that we treat, from burn injury and trauma, to malignancy. individuals may place less emphasis on appearance, constraining aesthetic surgery markets. we may see a retrenchment of healthcare funding away from the trauma and oncological care (including complex reconstruction) that benefits the individual, towards population level interventions in public health and infectious diseases. healthcare funders have long challenged, or misunderstood, the welfare benefits of plastic surgical interventions (such as breast reconstruction and limb salvage), they may seize the opportunity to stop whole sectors of activity, twisting priorities in the face of reduced healthcare spend secondary to economic contraction. both the public and the charitable sectors are likely to have reduced funding. there is likely to be particular constriction in research funding for functional and appearancerelated treatments, perhaps even for cancer care, as funding bodies first seek the treatment solutions for covid-19 then fund retrospective research into the pandemic, and as virology, immunology, and public health justifiably seek research funding prioritisation. plastic surgery has long been portrayed as a cinderella specialty, easily trivialised; it is imperative that as individuals and professional bodies we now prepare to robustly advocate for our patient groups, in terms of quality outcome measures and overall healthcare cost savings. research and audit activity should now focus even more onto outcome studies with robust objective measures and trial designs that cannot easily be deflected by competitors. as a specialty we need epidemiological and healthcare economic expertise as never before, and to invest in public relations to ensure we maintain broad public support. reconstruction should continue to restore socioeconomic productivity at a time when economic output will be challenged. many have analogised this pandemic to a battle, with frontline heroes fighting a lethal foe. although understandable, this battle analogy is an insidious misinterpretation. resolution will more likely come through longterm resilience, methodical organisation, and the rigorous repetition of simple measures than to acts of individual heroism. it will take common action by whole populations, enduring rather than fighting, and maintaining values and cohesion in a way that has become unfamiliar, in the west at least. the virus can be imagined everywhere in our communities but cannot be seen and directly targeted, in the military sense. if there is a better military analogy it is presumably political insurrection where the enemy blends unseen within a population, fear commonly outweighs the reality of risk, glorious victory is unlikely, and a conclusion typically comes through political compromise, plus societal and fiscal change. amongst the most likely changes will be the end of the west's hegemony over healthcare advances and its insistence that individual liberties override public health, several asian countries having just cause to claim better management of this disease. demographic change is inevitable, given the age-related increase in mortality from covid-19 (particularly where rationing of access to icu has had to occur), society being forced into the realisation that death is a natural part of life. this, or fiscal tightening of care budgets, may bring a changed emphasis upon end of life care, and whether healthcare is directed more toward quality of life and functional independence rather than upon prolonging life per se . depending upon the final public perception of how healthcare services have served their population, we may either see enhanced engagement in vaccination programmes and preventive care, or mistrust in medicine with a negative impact on early presentation, preventive healthcare and screening services. greater experience of virtual clinics may enhance remote healthcare delivery, and enable a change in referral pathways with, for example, plastic surgery services taking greater roles in early skin lesion triage and streamlining access to surgery. it is highly likely that travel will reduce, and the format of departmental / mdt activities, training and education, and major meetings will then need to change. virtual technologies, smaller targeted meetings, and increased use of online platforms will need to be embraced by bodies such as bapras euraps, es-pras, icoplast, and the wsrm if they are to retain their roles. these are massively challenging times, during which many of us will lose loved ones and colleagues, develop altered workforce roles, and have to look to define new practice and professional structures for the longterm. jpras supports global equity, internationalisation, and building a stronger community of plastic surgeons -we should not fall victim to short term pressures, but rather retrench to our core specialty strengths of innovation, excellence, and adaptability. we must advocate for a return to the delivery of high quality plastic surgical care, giving primacy to patient care approaches that are to the clear benefit of societies and economies, and not allow our specialty to be portrayed as defending vanity or individual greed. economies, societies, politics, and the demographics of whole continents are changing; healthcare and research funding priorities will follow. plastic surgery must continue to innovate and adapt, but now more than ever look to generate and disseminate high quality evidence of its positive impact on welfare, quality of life, overall healthcare efficiency, and population level capacity for productive independent living. covid-19 briefing notes moral injury: an integrative review guidance on at risk groups and social distancing key: cord-024982-4f6m3kfc authors: che huei, lin; ya-wen, lin; chiu ming, yang; li chen, hung; jong yi, wang; ming hung, lin title: occupational health and safety hazards faced by healthcare professionals in taiwan: a systematic review of risk factors and control strategies date: 2020-05-18 journal: sage open med doi: 10.1177/2050312120918999 sha: doc_id: 24982 cord_uid: 4f6m3kfc background: healthcare professionals in taiwan are exposed to a myriad of occupational health and safety hazards, including physical, biological, chemical, ergonomic, and psychosocial hazards. healthcare professionals working in hospitals and healthcare facilities are more likely to be subjected to these hazards than their counterparts working in other areas. objectives: this review aims to assess current research literature regarding this situation with a view to informing policy makers and practitioners about the risks of exposure and offer evidence-based recommendations on how to eliminate or reduce such risks. methods: using the preferred reporting items for systematic reviews and meta-analyses review strategy, we conducted a systematic review of studies related to occupational health and safety conducted between january 2000 and january 2019 using medline (ovid), pubmed, pmc, toxline, cinahl, plos one, and access pharmacy databases. results: the review detected 490 studies addressing the issue of occupational health and safety hazards; of these, 30 articles were included in this systematic review. these articles reported a variety of exposures faced by healthcare professionals. this review also revealed a number of strategies that can be adopted to control, eliminate, or reduce hazards to healthcare professionals in taiwan. conclusion: hospitals and healthcare facilities have many unique occupational health and safety hazards that can potentially affect the health and performance of healthcare professionals. the impact of such hazards on healthcare professionals poses a serious public health issue in taiwan; therefore, controlling, eliminating, or reducing exposure can contribute to a stronger healthcare workforce with great potential to improve patient care and the healthcare system in taiwan. eliminating or reducing hazards can best be achieved through engineering measures, administrative policy, and the use of personal protective equipment. implications: this review has research, policy, and practice implications and provides future students and researchers with information on systematic review methodologies based on the preferred reporting items for systematic reviews and meta-analyses strategy. it also identifies occupational health and safety risks and provides insights and strategies to address them. according to the world health organization (who), 1 an estimated 59 million people work in healthcare facilities globally, accounting for roughly 12% of the working population. the who 2 also reports that all healthcare workers, including healthcare professionals, are exposed to occupational hazards. the international labour organization (ilo) 3 reported that millions of healthcare workers suffer from work-related diseases and accidents, and many succumb to occupational hazards. scholars and practitioners in the field of healthcare and occupational health and safety (ohs) are striving to raise awareness of the risk factors and importance of workplace health and safety among this population. 1, 3, 4 schulte et al. 5 defined an occupational hazard as the shortterm and long-term dangers or risks associated with unhealthy workplace environments. tullar et al. 6 and joseph and joseph 7 stated that the healthcare workers at greatest risk are doctors, healthcare professionals, nurses, laboratory technicians, and medical waste handlers. occupational hazards pose health and safety risks and have negative impact on the economy, which accounts for roughly a 4% loss in global annual gross domestic product (i.e. $2.8 trillion annually). 3 the who, 2 ilo, 3 and nelson et al. 8 noted a lack of universally applicable data on the impact of occupational hazards. ohs hazards, and their negative impacts on health and well-being among healthcare professionals, is an issue of growing concern in the asia and pacific region, particularly in taiwan; however, research in this area has been somewhat limited. according to the taiwanese ministry of health and welfare (mohw) 9 in taiwan, 182,019 health and medical personnel are working at health care organizations in taiwan, including 33,516 healthcare professionals and 15,016 pharmacist assistants. the healthcare professionals serve a taiwanese population of 23,590,744 in 22,384 medical care institutions (490 hospitals and 21,894 clinics). 10 of the 490 hospitals, 81 are public and 409 are privately owned; of the 21,894 clinics, 440 are public and 21,454 are privately owned. 10 taiwanese healthcare professionals face a variety of ohs hazards, which increase the incidences of work-related disease, the country's burden of disease, the total number of accidents, the incidences of job-related health problems, and the number of cases involving incapacitation or disablement. 9 this study reviewed previous works on ohs hazards, as well as their risk factors and control strategies, with a focus on healthcare professionals in taiwan. cochrane 11 identified eight steps of a systematic review, which are adopted in this study. this study employed the preferred reporting items for systematic reviews and meta-analyses (prisma) protocol to organize the flow of information through the various steps of the review. we used the following key words in our literature search: occupational health and safety, risk factors, healthcare professionals, control strategies, and taiwan to ensure specificity and exclude irrelevant studies, we employed boolean logic (and, or, not) in combining terms as search strings. 12 the operator and was used to reduce the search yield for two key terms (e.g. "healthcare professionals (p) and occupational health and safety"). the operator or was used to increase the search yield (e.g. "healthcare professionals and occupational health and safety or risk factors"). note that in this example, the two search terms are synonyms. the operator "not" was used to exclude specific terms or term combinations. 13 this research obtained a large number of initial articles (n initial = 490); however, the application of inclusion and exclusion criteria considerably reduced the number of articles for inclusion in the review (n = 30 articles). the 30 articles focused on ohs, occupational hazards, and healthcare professionals in taiwan. figure 1 presents a flow diagram depicting the application of eligibility criteria, the process of identification and screening, and the reasons for inclusion and exclusion. in documenting and assessing individual publications, we collected key information from the relevant studies to populate an evidence table (see appendix c) and conducted a critical appraisal of the included studies. 12 the study population included adult pharmacy workers (male and female). data were extracted only from studies that included samples that were deemed significant given the justification of the authors of the studies. a critical appraisal of all studies was performed to assess their quality in terms of validity and reliability, as based on performance bias, information bias, selection bias, and detection bias. cochrane 11 and khan et al. 16 reported that biases tend to exaggerate or underestimate the "true" outcome of exposure to an occupational hazard. our ultimate objective was to compare (without any form of bias) groups that were exposed to occupational hazards and those that were not exposed in terms of risk factors and outcomes. 16 for the sake of validity and reliability, all of the studies selected for inclusion were prospective in nature and included data pertaining to exposure and outcomes, while controlling confounding factors. we also looked for studies with high internal reliability (consistency across items within a test) and high external reliability (consistency in agreeability between uses/rates). 12 in our final analysis, we considered whether the research had been conducted in an appropriate manner (internal validity). 13 we also considered the generalizability of the results, that is, whether the results were pertinent to other situations (external validity). data synthesis. the final step involved the synthesis of evidence from the included studies; that is, organized into homogeneous categories, under which the results were to be summarized. the evidence was also graded (i.e. assessed in terms of quality) and integrated (i.e. weighted across categories to address the multidisciplinary nature of ohs research). 12 in this review, the synthesis, grading, integration, interpretation, and summary of the evidence were presented in narrative form, due to difficulties in textual and statistical pooling. after completing our systematic review, we employed the prisma reporting scheme, which is endorsed for ohs studies by hempel et al. 12 briefly, the prisma structure is laid out in the following format: topic, summary/abstract, introduction, methods, results, conclusion, and recommendations. 12 a meta-analysis was not conducted. the ilo categorizes ohs hazards that affect healthcare professionals as biological, chemical, physical, ergonomics, and psychosocial. 17 from the 30 studies in this review, this study identified the ohs hazards, injuries, and diseases affecting healthcare professionals working in hospitals and healthcare facilities. this section provides the biological hazards, as identified in the review, as the most commonly encountered in hospitals and healthcare facilities in taiwan. according to who, the managers and administrators of hospital and healthcare facilities, in our case those in taiwan, should carefully assess the potential for exposure to biohazards and put effective biohazard control plans in place. the following chart provides a summary of the identified biological hazards, their risk factors, and control strategies (table 1) . the review established some of the most commonly faced chemical hazards present in hospitals and healthcare immunization and vaccines; 18 and biological safety cabinets, needleless systems or safety-engineered needles, suitable ventilation, and an appropriate medical waste management system. 15 administrative controls: written and documented infection control plans; decontamination procedures; enforcement of these systems; and the training of hospital staff in the implementation of occupational health and safety measures. 20 immunization programs; detection and followup of infections; periodic screening; codes of practice; and staff orientation. designing all work systems with the aim of minimizing the risk of exposure. personal protective equipment (ppe): includes devices for the protection of the eyes (e.g. face shields, goggles), respiratory system (e.g. surgical masks), and skin (e.g. latex gloves, protective aprons, gown. 20 based on risk assessments and careful training. [21] [22] [23] infection from human immunodeficiency virus (hiv), hepatitis b virus (hbv), and hepatitis c virus (hcv) 14 needle-stick injuries (nsi) and accidents with other sharp objects: occupational exposure resulting in hiv, hbv surface antigen-positive, or hcv transmission is largely due to inoculation of pathogens into cutaneous abrasions, lesions, scratches, or burns, as well as mucocutaneous exposure involving inoculation or accidental splashes onto non-intact mucosal surfaces of the nose, mucous membranes, mouth, or eyes. 24 facilities, as well as the documented control strategies, which are summarized in table 2 . physical hazards, which are defined as environmental risk factors that can harm the body without contact, were found to account for a substantial proportion of risks among healthcare professionals in taiwan. 4, [42] [43] [44] the physical hazards, risk factors, and control strategies are summarized in table 3 . the review established that healthcare professionals are exposed to musculoskeletal disorders and injuries, such as low back pain due to the nature of their work, such as lifting patients. 44 table 4 summarizes the risk factors and control strategies for this hazard. psychosocial hazards have attracted considerable attention in the research community, as well as among policy makers and practitioners in healthcare. [53] [54] [55] this study found that in taiwan, psychosocial hazards have prompted a larger number of studies combining physical, chemical, and biological hazards. the who 56 reported that psychosocial hazards are closely linked to work-related stress, workplace violence (e.g. violent patients), and other workplace stressors. table 5 provides a summary of the risk factors and control strategies of psychosocial hazards. this review provides detailed information regarding the ohs hazards that affect healthcare professionals working in hospitals and healthcare facilities in taiwan. the review summarizes the risk factors for hazards, as well as the control strategies to control, eliminate, or reduce them. from the reviewed studies, it was clear that ohs hazards can potentially result in a number of injuries, sickness, and harm. a wide range of ohs hazards were identified, including biological hazards 14 chemical hazards, 65 ergonomic hazards, psychosocial hazards, and physical hazards. 59, 62 the review has shown that healthcare professionals are at a significantly high risk of occupational related hazards. 56 injuries and sickness prevent healthcare workers from discharging their duties effectively, which can have negative impact on the overall healthcare system in taiwan. physical hazards, such as falls, noise, and mechanical hazards, could have long-term physiological effects, such as hearing impairments; therefore, there is need to introduce various control strategies, such as engineering noise control measures. there should be the provision of good ppe for healthcare professionals to protect themselves from physical harms in the workplace. according to our findings, it is evident that healthcare professionals are exposed to chemical hazards, some of which can be carcinogenic. there is also the risk of exposure to occupational dermatitis. it is therefore important that healthcare professionals are screened for cancer on a regular basis. the workers can also be trained about skin care and be provided with safety equipment and other useful interventions, such as sunscreen cream. such efforts can help in early detection, prevention, and intervention. as part of their routine occupation, biological hazards can affect healthcare professionals due to contact with patients and visitors. the review of healthcare professionals on duty demonstrates how important it is to manage blood borne and airborne biological pathogens in the healthcare workforce. 20 there should be administrative guidance and training on how healthcare professionals can deal with biological hazards, and these professionals should be encouraged to report work-related incidents as soon as they occur or are suspected to have occurred to aid early intervention. ergonomic hazards in healthcare professionals tend to arise from lifting patients and hospital equipment. this requires careful prevention, assessment, and intervention, as the impact of ergonomic hazards on the musculoskeletal system of the affected healthcare professionals cannot be ignored. 34 hospital administrators need to alleviate frequent job pressures by providing the necessary safe and ergonomic equipment, and hiring an adequate number of personnel. the professionals can work in properly planned shifts and teams to reduce fatigue, they should be trained in the correct techniques for lifting patients and equipment, and policies should be enforced to ensure compliance. the findings on psychosocial hazards show that healthcare professionals can be affected by mental and psychological hazards, such as stress, as it is evident that healthcare professionals who suffer from stress are likely to suffer from fatigue and exhaustion. healthcare professionals are trained to show less emotion, and thus, find it difficult to seek medical intervention. there is need for counseling and stress management for healthcare professionals, and the workers should be trained to manage stress. the workplace should be designed in such a manner as to prevent invasion, harassment, and violence against healthcare professionals. overall, hospital administrations and healthcare professionals should focus on evidence-based strategies (engineering, administrative, and ppe) to manage ohs hazards. the increasing prevalence of occupational hazards and work-related diseases among healthcare professionals in taiwan is a concern. 66 risk factors include exposure to hazards and a failure to follow hierarchical control strategies. health care workers and administrators must work together to eliminate or minimize these hazards through the introduction of and strict adherence to engineering, administrative, and personal protective equipment (ppe) controls. the the main routes of exposure to chemical hazards include ingestion, injection, skin contact or absorption, and inhalation. 34, 35 contamination and exposure are both affected by the duration and frequency of exposure, the quantity of drugs undergoing preparation, and the use of ppe. 23 the adverse health effects can be attributed to compounds deemed carcinogenic (cancer causing), mutagenic (promoting mutations), teratogenic (causing birth defects), or toxic to various organs. 36 alcohol hand sanitizers commonly used by healthcare professionals are flammable and harmful to the skin. there have also been reports on the dangers of detergents used to clean surfaces, which can lead to irritation and promote allergies of the skin, eyes, and respiratory tract. 35, 37 there is also evidence that some detergents can react with other products commonly stocked in healthcare facilities to produce toxic vapors. 31, 35, 38 it has been found that low concentration disinfectants, such as quaternary ammonium salts, alcohols, hydrogen peroxide, iodophors, and phenolic and chlorine compounds, can have toxic effects and irritate the skin, eyes, and respiratory system. 23 the inhalation of powdered medications and vapors exposes healthcare professionals to the risk of poisoning and allergic reactions. 39, 40 engineering control strategies: isolating and segregating hospital or healthcare facility areas and equipment; providing exhaust hoods to provide local ventilation when compounding and mixing drugs; providing biological safety cabinets to safeguard chemicals; and providing containers to prevent needle stick injuries. flammable chemicals should be stored away from sources of ignition and dangerous chemicals substituted with less harmful ones. 36 cuts, burns, hearing loss, motion sickness, and muscle cramps. 47 engineering controls: minimize the use of sharp tools, use machine guarding, use quality sockets, and close water faucets when not in use. 48 administrative controls: promote and practice safe work procedures, such as when using electrical equipment (e.g. cords). 18 educating workers about the cleaning equipment and cleaning up broken glass is also recommended. 49 ppe: use of appropriate footwear, gloves, eye and nose protection, and protective clothing 18 3. tripping, slipping, cuts, and falling poor housekeeping, poor layout, and slippery tiled floors. 50 open power cables, live wires, broken glassware, lancets, knives, scissors, and scalpels. 47 bruised skin, cuts, broken bones, and muscular injuries. 50 engineering control: proper lighting, the construction of safe stairwells, and regular building maintenance (e.g. floors and workspaces). 44 ppe: use of appropriate footwear, gloves, eye and nose protection, and protective clothing 18 4. exposure to microwave radiation, and ionizing and non-ionizing radiation. 50 risks imposed by radiation from x-ray machines and other diagnostic imaging systems, and the radionuclides used in nuclear medicine and radiation therapy. workers face risks from nonionizing radiation, lasers, ultraviolet rays, and magnetic resonance imaging. 51 the risk increases when using heat sealers and poorly maintained or insulated radio-diagnostic equipment. 48 tissue damage, risk of cancer, and abnormal cell mutation (e.g. abnormal leukocytes). 48,51 engineering control: reducing the time of exposure, increasing the distance to x-ray machines, and increasing the amount of shielding. 20 ppe: use of appropriate footwear, gloves, eye and nose protection, and protective clothing 18 perceptions of workers can greatly affect their implementation of risk-mitigation strategies. 20 selection bias is a concern here, despite the fact that we selected published and peer-reviewed articles, as well as unpublished but authoritative gray articles; the fact is that other unverifiable but potentially valuable reports were no doubt excluded. 67 our reliance on observational studies (to the exclusion of intervention studies) and the heterogeneity of the included articles (in terms of methodology) posed a risk of bias and limited standardization. 68 this study discovered relatively little research focusing on hospital workers in taiwan, and thus, further empirical studies focusing on this group of healthcare givers are required and recommended. 68 researchers should focus on the health status, work performance, and workplace retention of healthcare professionals, including the prevalence of morbidity and mortality. 67 the insights in this review provide a valuable reference for policy makers in establishing goals to deal with workplace hazards. 68 hazard control strategies must be based on objective assessments of existing risks and the most appropriate measures to deal with them. 20 this systematic review confirmed a positive correlation between ohs hazards (biological, physical, chemical, and psychosocial), and work-related injuries, occupational health problems, and work-related diseases. the burden of disease and attributable fraction of work-related diseases and occupational injuries has been shown to cause considerable social and economic losses for employees, families, companies, countries, and societies at large. 8 generally, the burden of disease is assessed using disease/disability adjusted life years. the burden of disease is measured as the impact of morbidity and premature mortality within a given area. 2, 69 scholars and professionals agree that reducing, substituting, or eliminating ohs hazards in healthcare facilities is important for healthcare workers, helps to ensure patient safety, and enhances the overall quality of healthcare. 7 many researchers have used the "hierarchy of controls," which is based on the assumption that interventions are most effective when implemented at the source and least effective when applied at the worker level. 20 gorman et al. listed control interventions from most to least effective as follows: elimination, substitution, engineering, administrative, and ppe. researchers have also emphasized the importance of eliminating hazards or substituting hazardous materials with less hazardous materials. 20, 70 taimela et al. 71 argued that administrative controls, such as training and ensuring adequate staffing, are crucial to eliminating or minimizing occupational hazards. engineering controls, such as redesigning work spaces, ensuring adequate ventilation, and introducing automated systems for repetitive tasks, were emphasized by liberati et al. 72 ppe, such as the use of gloves, clothing, and eye wear, are considered the least effective and have the most profound consequences in the event of failure by exposing the individual directly to the hazard. 20 nonetheless, many researchers and professionals agree that all such controls should be applied collectively, in order to minimize the effects of hazards. 20,70-72 musculoskeletal disorders (msds) due to repetitive actions, less than optimal computer equipment, and a poorly engineered workspace in which healthcare professionals are forced to overreach and/or sit while maintaining an awkward posture. 43 healthcare professionals are tasked with lifting and transferring equipment, tools, and instruments. one's physical fitness level and demographic background were shown to affect the risk of developing msds. 52 workplace and job-related demands, poor administrative and team support, and a negative attitude toward job tasks were all strongly correlated with msds. 47 ergonomic hazards can lead to chronic pain in the arms, back, or neck. frequently, they lead to msds, such as carpel tunnel syndrome, which tends to reduce work performance and productivity and can have a serious detrimental effect on one's health-related quality of life. 50 strained movement due to localized pain, stiffness, sleep disturbances, twitching muscles, burning sensations, and feelings of overworked muscles. 47 engineering control strategies: redesign workstations with appropriate chairs and computer equipment. 43 workstations should be configurable to a wide range of medical personnel with different body shapes and sizes. it is also recommended that lifting and handling equipment, such as trolleys, be installed in areas requiring heavy lifting. automation should be adopted when resources and practicability allow. 46 59 healthcare professionals also face violence during robberies and the theft of addictive prescription pain killers, such as oxycontin and vicodin. 54 we also identified organizational culture and structure, interpersonal relationships at work, job content and satisfaction, homework balance, and the changing nature of work as important psychosocial hazard risk factors among healthcare professionals. 54, 57, 60 work-related stressors have a detrimental impact on worker's health and safety, in terms of mental, musculoskeletal, chronic degenerative disorders, metabolic syndrome diabetes, and cardiovascular diseases. 61 psychological hazards at work were associated with heart disease, depression, physical health problems, and psychological strain. 54 low back pain was the most common work-related ailment among healthcare workers in taiwan. 53 employees who experience job insecurity and/or workplace injustice were more likely to suffer from burnout. 54 job demands and the level of control experienced by the worker were significantly associated with fatigue; exposure to workplace violence affects psychological stress, sleep quality, and subjective health status among healthcare professionals. 59 engineering control strategies: creation of isolation areas for agitated patients and designing an office layout that prevents the healthcare professionals from coming into direct contact with customers/patients or being trapped. 57 spaces should be well lit and separated to ensure that client-care provider contact is controlled and access is allowed only when absolutely necessary. proper working communication devices and video surveillance, as well as panic buttons and alarm systems. 62 administrative control: management policies make unequivocal declarations of non-violence/anti-abuse. 63 management can encourage workers to participate in the design of forwardrotating (day-evening-night) shifts and work schedules that impose gradual shift changes and ease the adaptation to nonregular work shifts to ensure that all concerned get adequate sleep. 61 educate healthcare professionals about the risks associated with shift work. 20 well-trained security personnel should be hired to deal with unruly customers. 59 training in conflict management and problem-solving could also help workers to prevent or de-escalate violence. 60, 64 nametags should be used by employees, and reporting and response procedures should be enhanced. the manuscript has not previously been published and is not under consideration by another journal. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the ethical approval was not sought for this study because this is a systematic review and all the literature has been published. the author(s) received no financial support for the research, authorship, and/or publication of this article. lin ming hung https://orcid.org/0000-0002-7798-826x supplemental material for this article is available online. occupational health: health workers occupational health: data and statistics international labour standards on occupational safety and health workplace safety and health: healthcare workers interaction of occupational and personal risk factors in workforce health and safety occupational safety and health interventions to reduce musculoskeletal symptoms in the health care sector the health of the healthcare workers the global burden of selected occupational diseases and injury risks: methodology and summary national development council (ndc) what is a systematic review systematic reviews for occupational safety and health questions: resources for evidence synthesis a search strategy for occupational health intervention studies risk and management of blood-borne infections in health care workers the occupational safety of health professionals working at community and family health centers five steps to conducting a systematic review sleep disorder in taiwanese nurses: a random sample survey safety culture in a pharmacy setting using a pharmacy survey on patient safety culture: a cross-sectional study in china science of safety topic coverage in experiential education in us and taiwan colleges and schools of pharmacy controlling health hazards to hospital workers perception and prevalence of work-related health hazards among health care workers in public health facilities in southern india the prevalence of occupational health-related problems in dentistry: a review of the literature workplace safety and health improvements through a labor/management training and collaboration tuberculosis in healthcare workers: a matched cohort study in taiwan health care visits as a risk factor for tuberculosis in taiwan: a population-based casecontrol study estimation of the risk of bloodborne pathogens to health care workers after a needlestick injury in taiwan epidemiological profile of tuberculosis cases reported among health care workers at the university hospital in vitoria, brazil risk of tuberculosis among healthcare workers in an intermediate-burden country: a nationwide population study risk of tuberculosis infection and disease associated with work in health care settings sars in healthcare facilities reproductive health risks associated with occupational exposures to antineoplastic drugs in health care settings: a review of the evidence overview of emerging contaminants and associated human health effects guidelines for safe handling of hazardous drugs: a systematic review critical care medicine in taiwan from 1997 to 2013 under national health insurance niosh health and safety practices survey of healthcare workers: training and awareness of employer safety procedures potential risks of pharmacy compounding development of taiwan's strategies for regulating nanotechnology-based pharmaceuticals harmonized with international considerations an overview of the healthcare system in taiwan chemical and biological work-related risks across occupations in europe: a review n-hexane intoxication in a chinese medicine pharmaceutical plant: a case report occupational neurotoxic diseases in taiwan the impact of physical and ergonomic hazards on poultry abattoir processing workers: a review musculoskeletal disorders and ergonomic hazards among iranian physicians occupational safety and related impacts on health and the environment prevalence of workplace violent episodes experienced by nurses in acute psychiatric settings occupational hazards in the thai healthcare sector prevalence of work related musculoskeletal disorders (wmsds) and ergonomic risk assessment among readymade garment workers of bangladesh: a cross sectional study the study of the effects of ionizing and non-ionizing radiations on birth weight of newborns to exposed mothers healthcare worker safety: a vital component of surgical capacity development in low-resource settings comparisons of musculoskeletal disorders among ten different medical professions in taiwan: a nationwide, population-based study occupational exposure to ionizing and non-ionizing radiation and risk of glioma effect of systematic ergonomic hazard identification and control implementation on musculoskeletal disorder and injury risk the impact of occupational psychological hazards and metabolic syndrome on the 8-year risk of cardiovascular diseases-a longitudinal study employment insecurity, workplace justice and employees' burnout in taiwanese employees: a validation study risks of treated anxiety, depression, and insomnia among nurses: a nationwide longitudinal cohort study occupational health: occupational and work-related diseases tackling psychosocial hazards at work violence against health workers in family medicine centers impact of workplace violence and compassionate behaviour in hospitals on stress, sleep quality and subjective health status among chinese nurses: a cross-sectional survey the association between jobrelated psychosocial factors and prolonged fatigue among industrial employees in taiwan psychosocial factors and workers' health and safety psychosocial hazard analysis in a heterogeneous workforce: determinants of work stress in blue-and white-collar workers of the european steel industry an evaluation of the policy context on psychosocial risks and mental health in the workplace in the european union: achievements, challenges, and the future a national study on nurses' exposure to occupational violence in lebanon: prevalence, consequences and associated factors review of the literature on determinants of chemical hazard information recall among workers and consumers prevalence and determinants of workplace violence of health care workers in a psychiatric hospital in taiwan a brief overview of systematic reviews and meta-analyses maximizing the impact of systematic reviews in health care decision making: a systematic scoping review of knowledge-translation resources the global burden of occupational disease hazard identification, risk assessment, and control measures as an effective tool of occupational health assessment of hazardous process in an iron ore pelletizing industry an occupational health intervention programme for workers at high risk for sickness absence. cost effectiveness analysis based on a randomised controlled trial learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare key: cord-305941-277iqp0u authors: bozdağ, faruk; ergün, naif title: psychological resilience of healthcare professionals during covid-19 pandemic date: 2020-10-13 journal: psychol rep doi: 10.1177/0033294120965477 sha: doc_id: 305941 cord_uid: 277iqp0u the covid-19 pandemic as a public health issue has spread to the rest of the world. although the wellbeing and emotional resilience of healthcare professionals are key components of continuing healthcare services during the covid-19 pandemic, healthcare professionals have been observed in this period to experience serious psychological problems and to be at risk in terms of mental health. therefore, this study aims to probe psychological resilience of healthcare workers. the findings of this study showed that in order to raise psychological resilience of healthcare professionals working during the covid-19 pandemic their quality of sleep, positive emotions and life satisfaction need to be enhanced. psychological resilience levels of healthcare workers in their later years were found to be higher. doctors constitute the group with the lowest levels of psychological resilience among healthcare workers. the current study is considered to have contributed to the literature in this regard. primary needs such as sleep which are determinants of quality of life, life satisfaction and psychological resilience should be met. the covid-19 pandemic, which emerged in the chinese city of wuhan in december 2019 and has since spread to the rest of the world, has been described as a public health issue causing international concerns. the covid-19 disease has caused and still causes health problems in over 3.3 million people worldwide as of may 3, 2020 (world health organization, 2020). healthcare professionals have been observed in this period to experience serious psychological problems and to be at risk in terms of mental health (black dog institute, 2020; inchausti et al., 2020; lai et al., 2020) . defined as a global pandemic, covid-19 can lead to stress, apprehension and anxiety. mood management is required to avoid exacerbation of stress and anxiety (australian psychological society, 2020) . it is essential that potential psychosocial impact of covid-19 on healthcare workers is investigated (arden & chilcot, 2020) . healthcare workers constitute the most affected group of people in the fight against the covid-19 virus. among the common mental effects of the pandemic are anxiety, panic, depression, anger, confusion, ambivalence and financial stress. healthcare workers were observed to experience similar problems during previous pandemics (black dog institute, 2020) . depression, anxiety and posttraumatic stress disorder are the most common psychological disorders that were reported particularly in healthcare professionals during the 2003 sars and 2014 ebola virus pandemics (dong & bouey, 2020; maunder et al., 2006; tam et al., 2004) . studies have also shown that healthcare professionals are considerably more worried about catching the infection during a pandemic (chua et al., 2004) . exposure to covid-19 patients raises anxiety and fear of virus infection. as a result, levels of stress, depression and anxiety rise in healthcare workers and they might become traumatized (mcalonan et al., 2007) . according to cullen et al. (2020) , particularly those working in public health, primary care, emergency service and intensive care are at the risk of developing psychological symptoms. studies conducted in china have revealed that healthcare workers are exposed to work overload, isolation and discrimination, and therefore they experience exhaustion, fear, affective disorders and sleep problems (w. . in a study conducted with 1563 healthcare workers, more than half of the workers (50.7%) reported depression symptoms, 44.7% anxiety and 36.1% sleep disorder . in a similar study carried out in singapore, healthcare professionals were reported to experience depression, stress, anxiety and posttraumatic stress disorder . as the research studies cited above show, it is crucial that mental health of healthcare workers is protected during the covid-19 pandemic. in this regard, numerous reports coming out of china stress the importance of protecting mental health of healthcare workers (denis et al., 2020) . achieving a sustainable success in the provision of healthcare services depends on the morale and sound mental wellbeing of healthcare workers (low & wilder-smith, 2005) . in the pandemic period, psychological resilience in particular rises in prominence (g. smith et al., 2020) . the covid-19 pandemic is considered a threat to psychological resilience . according to the american psychological association (2020), it is particularly crucial to promote psychological resilience of healthcare professionals during the pandemic. individuals who may be exposed to numerous hardships as well as shocking, destructive and stressful incidents differ in their reactions and coping strategies. some individuals react to stressful and traumatic situations by yielding to psychological disorders such as anxiety and depression while others recover from negative mental state in a short time and resume their normal lives. this power that people who recover and resume their lives possess is referred to as psychological resilience in positive psychology approach (do gan, 2015) . studies point to optimistic perspectives whereby most people become stronger fighting the difficulties they face through psychological resilience (polizzi & lynn, 2020) . psychological resilience can be defined, in the broadest sense, the individual's ability to withstand hardship (jackson et al., 2007) . defined as adapting to changes caused by stressful events in a flexible way and recovering from negative emotional experiences (tugade & fredrickson, 2004) , psychological resilience impacts on the illness process and the subsequent health (naeem et al., 2020) . psychological resilience is reported to be related to symptoms of anxiety and depression in healthcare professionals (foureur et al., 2013) . previous studies have argued that psychological resilience needs to be investigated through a systems approach that utilizes a multilevel interaction process between the individual and the environment. psychological resilience is an ecological phenomenon and therefore it ought to be developed through environmental interactions such as family, community and society. the spaces individuals occupy contain the risk of producing various problems. however, the possibility of engendering positive outcomes may rise as well. creating positive environmental conditions is likely to eliminate the risks for the individual (brown & westaway, 2011; greene, 2002) . according to fergus and zimmerman (2005) , it is essential that psychological resilience is approached with an ecological perspective. such an approach should consider the impact of environmental factors, as well as individual factors, in reducing risk elements. therefore, any investigation of psychological resilience of healthcare workers needs to consider both environmental and individual factors. the wellbeing and emotional resilience of healthcare professionals are key components of continuing healthcare services during the covid-19 pandemic, as stated by the national center for ptsd (2020). thus, it is critical to anticipate the stresses linked to this process and providing support to healthcare professionals. tracking and assessing the wellbeing of healthcare workers is important in terms of ensuring their successful reintegration with their coworkers in case they get infected. at this point, both institutional supports and selfcare strategies come into play. therefore, a holistic assessment confirms the need to research psychological resilience of healthcare workers both at individual and environmental level. in turkey, the number of people infected by the covid-19 virus is 122 392 as of 3 may 2020 (world health organization, 2020) and this number is growing each day. this increase naturally affects the quality of healthcare services. psychological resilience of healthcare workers needs to be improved and sustained in order to maintain the quality of healthcare services. resilient mental state of healthcare workers influences not only their professional lives but their social and personal lives as well. although the importance of healthcare workers has become established in turkey, occasionally certain negative incidents occur. healthcare workers are from time to time psychologically traumatized as they are stigmatized and discriminated against by certain segments of the society. on the other hand, the positive impact of the support offered to healthcare workers cannot be overlooked either. during the pandemic, for instance, the society in turkey has been clapping from balconies in show of its appreciation to healthcare workers. to extend the effect of this positive atmosphere and enhance psychological resilience of healthcare workers at environmental and personal level, the current study attempts to investigate the factors impacting on psychological resilience of healthcare workers. a wide gap has been reported in the literature concerning psychological resilience practices during long-term pandemic periods (buheji et al., 2020) . a related search of the literature revealed only a single research study examining psychological resilience of healthcare professional during the covid-19 virus outbreak. considering the knowledge gap in the literature and with a view to improving the effectiveness of psychological support to be provided to healthcare workers, this study aims to probe psychological resilience of healthcare workers. the ecological framework was utilized to determine the variables impacting on psychological resilience. accordingly, among the probed individual variables are gender, age, having children or not, taking personal precautions against the risk of becoming infected with the covid-19 virus, worry about transmitting the virus to family/relatives, quality of nutrition and sleep, positive-negative affective state and life satisfaction, while environmental 4 psychological reports 0(0) variables include weekly workload, organizational measures against the risk of becoming infected with the covid-19 virus, perceived social support (perceived support by family, friends and someone special) and perceived organizational support. data were collected online for four days between 6 and 10 april 2020. the brief resilience scale (brs). the scale was developed by b. smith et al. (2008) to measure individual psychological resilience. it consists of six items (three questions reverse) measured on a 5-point scale (1 never suitable and 5 completely suitable). the total score range was between 6 and 30. higher scores on the scale indicate a higher level of psychological resilience. the turkish version of the scale was adapted by do gan (2015). the adapted scale was highly sufficient in terms of cfa values (v 2 /df (12.86/7) ¼ 1,83, nfi ¼ 0.99, cfi ¼ 0.99, gfi ¼ 0.99, srmr ¼ 0.03, rmsea ¼ 0.05) and internal consistency coefficient (a ¼ .88). in this study, the internal consistency coefficient was found as .82. survey of perceived organizational support (spos) brief form. the original scale of spos consists of 36 items and was developed by eisenberger et al. (1986) . however, they later recommended using a shorter version of the scale consisting of 17 items (eisenberger et al., 1986) . the turkish version of spos was adapted by azaklı (2014) . indeed, first the longer version of the scale was adapted to turkish with the adaptation of the shorter version coming afterwards. in the turkish version of the brief scale, there were 16 items in a 6-point likert type scale (1: completely disagree and 6: completely agree) with high internal reliability (a ¼ .96). in this study, the shorter version of the scale was used. the internal reliability of the scale in this study was also excellent (a ¼ .92). multidimensional scale of perceived social support (mspss). mspss was developed by zimet et al. (1988) and adapted to turkish by eker and arkar (1995) . satisfaction with life scale (swls). swls consists of five items measured on a 7-point likert type scale (1: strongly disagree, 7: strongly agree). it was developed by diener et al. (1985) and adapted to turkish by k€ oker (1991) . higher scores on the scale indicate higher levels of life satisfaction. the test-retest reliability coefficient of the scale was found .85. in the current study, the cronbach alpha value was excellent (a ¼ .91). positive and negative affect schedule (panas). panas is a self-report measurement tool and consists of 20 items (ten items measure positive and other ten items measure negative affect) measured on a 5-point likert type scale (1: very slightly or not at all, 5: extremely). it was developed by watson et al. (1988) and adapted to turkish by genc¸€ oz (2000). scores range from 10 to 50 for both sets of items. higher scores of positive items indicate having a high positive affect and lower scores of negative items indicate a less negative affect. the internal consistency coefficient of the turkish version was .83 for negative affect and .86 for positive affect. in this study, internal reliability was .87 for positive affect and .88 for negative affect. questionnaire. eight questions were prepared by the researchers to assess the situation of healthcare professionals during the covid-19 pandemic. these questions included quality of sleep and nutrition, the risk of being infected by the virus, worry about transmitting the virus to their relatives etc. the questions were measured by a 5-point likert type scale. the questions are: "do you think adequate precautions are taken against the risk of coronavirus transmission in your institution? (1: the precautions are very poor, 5: the precautions are extremely enough)", "do you take adequate precautions individually to protect yourself against coronavirus? (1: never, 5: extremely)", "what is your risk of getting coronavirus in the unit you work in? (1: not at all, 5: extremely)", "have you ever worked with someone who has a coronavirus infection? (1: never, 5: extremely)", "are you worried about being infected due to the risk at your work? (1: never, 5: extremely)", "are you worried to transmit coronavirus to your family members/relatives/friends because of your job? (1: never, 5: extremely)", "how do you evaluate your nutritional quality? (1: pretty inadequate, 5: quite enough)" and "how would you rate your sleep quality for the last few weeks? (1: pretty inadequate, 5: quite enough)". psychological reports 0(0) the entire surveys were prepared online and the link was shared with anyone who could voluntarily participate in the study. the participants from around 20 cities across turkey filled out the questionnaire. the participants were informed about the study aims and procedures of the research. no reward was offered for participating. no personally identifiable information was requested. for the analysis of the study, pearson's correlation analysis and hierarchical linear regression analysis were used. before conducting the analysis, the normality of the items and the scale were checked. it was seen that skewness and kurtosis value of most of the items were between à1 to þ1 and some items' skewness and kurtosis value were between à3 to þ3. the data can be considered to be normally distributed (kim, 2013; kline, 2011) . moreover, sample size, univariate and multivariate outliers, normality, linearity, homoscedasticity, multicollinearity and independence of errors assumptions were calculated for hierarchical linear regression (hair et al., 2014) . no outliers were found in the data set and the sample size of 214 participants can be considered as sufficient in accordance with the criteria [n ! 50 þ 8 m (the number of independent variables in m)] (tabachnick and fidell, 2012) . the scatter plots of the residues were examined, and it was observed that the assumptions of normality, linearity and homoscedasticity were met. for multicollinearity, it was assumed that the correlation coefficient between variables is less than .80, vif (variance inflation factor) is less than 10 and tv (tolerance value) is greater than .10 (field, 2009) . bivariate correlations between the variables are given in table 1 . the fact that vif values of independent variables were between 1.25 and 4.77 (just three measurements were higher than 3) and tvs were between .21 (just one measurement was lower than .3) and .80 showed that multicollinearity assumption was met. finally, the durbin-watson value was calculated as 1.97 and the assumption of independence of errors was met (field, 2009) . means and standard deviation intercorrelation between variables were calculated and shown in table 1 . psychological resilience significantly and positively correlated with life satisfaction, positive affect, sub-scales of perceived social support, participants' age, taking personal precautions against coronavirus, nutrition and quality of sleep, meaning that an increasing level of psychological resilience leads to a higher level of the variables and vice versa. however, psychological resilience significantly and negatively correlated with negative affect, personally feeling in risk because of being healthcare professional, and worrying about being infected by the virus, meaning that decreasing level of psychological resilience leads to a rising level of the variables and vice versa. before regression analysis, t test for psychological resilience of women and men, and one-way anova for types of occupations (doctors vs nurses vs other healthcare professionals) were calculated. the result of t test showed that differences between psychological resilience of women (m ¼ 17.94, sd ¼ 3.62) and men (m ¼ 19.05, sd ¼ 2.75) were statistically significant t (214) ¼ -2.47, p ¼ .014. the level of psychological resilience of men was higher than that of women. difference between types of occupations in terms of the psychological resilience level indicated that although there were differences between the level of psychological resilience among the types of healthcare workers, the model was not statistically significant f (2, 211) ¼ 2.96, p ¼ .054. however, bonferroni test showed that the level of psychological resilience of doctors (m ¼ 17.70, sd ¼ 3.01) and other healthcare professionals (m ¼ 19.03, sd ¼ 3.22) statistically and significantly differs, p ¼ .048. but there were no statistical differences between doctors and nurses (m ¼ 18.45, sd ¼ 3.58), and nurses and other healthcare professionals. a high correlation between psychological resilience and other variables showed further analysis was warranted (see table 1 ). in table 2 , the hierarchical regression model was calculated to see how psychological resilience was predicted in terms of demographic variables, questions related to covid-19, and variables related to perceived support and personal feeling that were used in the study. in model 1, demographic variables were calculated and it was found that gender, age, the types of occupation (doctors, nurses and other healthcare professionals), and having a child/children significantly predicted psychological resilience. but, having children (b ¼ -.24) and being a doctor (b ¼ -.20) negatively predicted psychological resilience. overall, model 1 significantly predicted and explained 12% of the variance in the psychological resilience of healthcare professionals. model 2 showed that demographic variables and questions related to covid-19 together significantly predicted and explained 31% of the variance in the psychological resilience of healthcare professionals. in model 2, age, occupation, worry about becoming infected by the virus and quality of sleep significantly predicted the psychological resilience of healthcare professionals. finally, model 3 showed that all variables shown in table 2 significantly predicted the psychological resilience of healthcare professionals and explained 43% of the variance. in model 3, age and occupation (doctor), quality of sleep, positive and negative affect, and life satisfaction significantly predicted the psychological resilience of healthcare professionals. healthcare professional are forced to work under extremely difficult conditions owing to the covid-19 virus outbreak (greenberg et al., 2020) . under such circumstances, many essential healthcare workers become psychologically traumatized and need psychological support. it is argued that psychological bozda g and ergün 9 supports to be offered to these workers ought to be based on psychological resilience models (maunder et al., 2010) . it is critical that psychological resilience of healthcare workers is protected and maintained during the pandemic (bc centre for disease control, 2020; santarone et al., 2020) . this study too aimed to determine the factors impacting on psychological resilience with the hope of aiding psychological support services to be provided to healthcare workers. three models were tested through hierarchical regression analysis that was performed to specify the factors influencing psychological resilience of healthcare professionals. the first model looked into whether certain demographic variables predicted healthcare workers' psychological resilience. the results showed that, in order of importance, age, having children, occupation and gender variables significantly predicted healthcare workers' psychological resilience. older age and being male heightened psychological resilience while being a doctor and having more children lowered psychological resilience. the second model revealed that, in order of importance, quality of sleep, age, worry about becoming infected by the virus and occupation variables significantly predicted healthcare workers' psychological resilience. thus, as the quality of sleep and age rose, so did healthcare workers' psychological resilience whereas heightened worry about becoming infected by the virus and being a physician lowered psychological resilience level. the final model concluded that, in order of importance, the quality of sleep, positive affective state, age, negative affective state, life satisfaction and occupation significantly predicted psychological resilience of healthcare workers. accordingly, higher levels of quality of sleep, positive affective state, age and life satisfaction raised the level of psychological resilience while higher negative affective state and being a doctor meant lower psychological resilience level. according to the results of the last model, particularly the quality of sleep, positive emotional state, age and life satisfaction were found to have a crucial impact on improving psychological resilience of healthcare workers. it has been frequently noted in the literature that quality sleep acts as a protective factor against the psychological problems that healthcare workers might experience (center for the study of traumatic stress, 2020; dewey et al., 2020; inter-agency standing committee, 2020; lai et al., 2020; liu et al., 2020; siyu et al., 2020) . healthcare workers face serious pressures that may cause psychological disorders, including anxiety, phobia, depression and insomnia (w. . according to lai et al. (2020) , a significant number of healthcare workers experience insomnia and develop symptoms of depression, anxiety and distress during the covid-19 pandemic. in another study conducted with 1563 healthcare professionals, over half of them reported depression symptoms (50.7%), 44.7% anxiety and 36.1% insomnia . similarly, a research study with 5393 participants showed that healthcare workers experienced depression, anxiety and insomnia (siyu et al., 2020) . psychological reports 0(0) going without sleep for a long period of time is a risk factor for healthcare professionals (inter-agency standing committee, 2020). therefore, it is crucial that healthcare workers' basic needs such as food, fluids and sleep are met during quarantine time. administrators of medical institutions need to ensure that healthcare workers get enough sleep (dewey et al., 2020) , thereby helping them stay psychologically more resilient. on the other hand, positive emotional state has been found to contribute to healthcare workers' psychological resilience. naeem et al. (2020) argue that individuals who actively develop positive emotions have higher psychological resilience. positive emotions have been found to decline in the wake of covid-19 pandemic (s. . governments and particularly medical leaders can focus on changing people's minds and thus heightening their psychological resilience levels (buheji et al., 2020) . busy work schedule and frequent exposure to negative incidents (deaths etc.) are considered as risk factors for healthcare workers. healthcare workers at their later years, however, have been observed to manage this time better and to be psychologically more resilient. a positive relationship between age and psychological resilience indicates that healthcare workers cope better with crises as they get older. as they gain more experience, healthcare workers become more skilled at handling negative situations and grow psychologically more resilient. during the pandemic, one of the primary objectives should be taking necessary precautions to improve positive emotions and psychological resilience of healthcare workers. research findings have shown that healthcare workers face mental health issues during the covid-19 virus outbreak (lai et al., 2020; liu et al., 2020; siyu et al., 2020) and this naturally impacts on their life satisfaction. the s. study has found an overall decline in life satisfaction following the covid-19 pandemic. the present study also revealed that healthcare workers who are at risk and the most affected group by the pandemic grow more resilient as their life satisfaction rises. accordingly, precautions ought to be taken to fight mostly commonly experienced problems such as anxiety, depression and apprehension in order to raise life satisfaction and thereby psychological resilience of healthcare workers. another result that came out of the current study is that negative affective state in healthcare workers significantly lowers their psychological resilience. furthermore, doctors were found to have considerably lower psychological resilience levels compared to other healthcare workers. individuals tend to develop negative emotions to protect themselves. people have reported heightened negative emotions during the covid-19 virus outbreak. prolonged negative affective state, however, may lead to various problems (s. . a negative relationship has been found between depression and anxiety, which are considered negative emotions in healthcare workers, and psychological resilience . this is consistent with the current study's findings. it is possible to heighten healthcare professionals' psychological resilience by lowering their negative emotions. however, this study's finding that doctors have lower psychological resilience levels contradicts what lin et al. (2020) found. in their study with 114 healthcare professionals, lin et al. (2020) found that doctors' psychological resilience is higher than other healthcare workers'. on the other hand, a study conducted in singapore reported that during the 2003 sars virus outbreak doctors carried more psychological symptoms risk compared to nurses (chan & huak, 2004) , while another study revealed that frontline doctors in direct contact with patients developed even more serious symptoms of anxiety and depression (siyu et al., 2020) . these findings are consistent with the findings of the current study. being in direct contact with patients, assuming more responsibilities and having a busy work schedule cause doctors to become exhausted and thus psychologically less resilient. the findings of this study revealed that in order to raise psychological resilience of healthcare professionals working during the covid-19 pandemic their quality of sleep, positive emotions and life satisfaction need to be enhanced. psychological resilience levels of healthcare workers in their later years were found to be higher. on the other hand, higher levels of negative emotional state lower psychological resilience level. doctors constitute the group with the lowest levels of psychological resilience among healthcare workers. the research findings have revealed a significant portion of the variables impacting on the psychological resilience of healthcare workers in order that they could offer more quality service during the covid-19 and similar pandemics. the current study is considered to have contributed to the literature in this regard. in addition, the result of the current study showed that quality of sleep, which is one of the primary needs, life satisfaction and positive-negative affairs are important prediction for the psychological resilience of healthcare professionals. therefore, it can be indicated that for taking quality healthcare services and raise healthcare performance at work, primary needs such as sleep, and life satisfaction should be provided and healthcare professionals are to work in good conditions. the current study also concludes that in order to enhance positive emotions and weaken negative emotions of healthcare professionals, the workers' needs ought to be prioritized in any practice. the comparatively small number of participants who provided data can be considered a limitation in terms of generalizability of the results. future studies may reveal more generalizable results by collecting data from a higher number of healthcare professionals. considering the current study is an example of psychological reports 0(0) cross-sectional research, it is necessary to conduct longitudinal studies that examine long-term effects of the pandemic. positive and negative emotions were found to play a significant role in the model as the variables that predict psychological resilience of healthcare workers were analyzed. therefore, further studies may have a better understanding of the issue through investigation of determinants of healthcare workers' positive and negative emotions during the covid-19 pandemic. in addition, life satisfaction and first needs such as sleep which can imply the quality of life were other important roles of impacting psychological resilience of healthcare professionals. therefore, it can be worked relationships between healthcare workers' quality of lives and psychological resilience during covid-19. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) received no financial support for the research, authorship, and/or publication of this article. faruk bozda g https://orcid.org/0000-0002-9862-2697 naif ergu¨n https://orcid.org/0000-0001-5346-5053 psychological research on past crises can help people cope with the daily-sometimes hourly-newsflashes about the coronavirus health psychology and the coronavirus (covid-19) global pandemic: a call for research tips for coping with coronavirus anxiety psychometric evaluation of the survey of perceived organizational support (spos) (doctoral dissertation) supporting the psychosocial well-being of health care providers during the novel coronavirus (covid-19) pandemic mental health ramifications of covid-19: the australian context agency, capacity, and resilience to environmental change: lessons from human development, well-being, and disasters minimising stress exposure during pandemics similar to covid-19 psychological effects of quarantine during the coronavirus outbreak: what healthcare providers need to know? psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in singapore stress and psychological impact on sars patients during the outbreak mental health in the covid-19 pandemic overview of information available to support the development of medical countermeasures and interventions against covid-19 supporting clinicians during the covid-19 pandemic the satisfaction with life scale kısa psikolojik sa glamlık € olc¸e gi'nin tu¨rkc¸e uyarlaması: gec¸erlik ve gu¨venirlik c¸alıs¸ması [adaptation of the brief resilience scale into turkish: a validity and reliability study public mental health crisis during covid-19 pandemic perceived organizational support ç ok boyutlu algılanan sosyal destek € olc¸e gi'nin fakt€ or yapısı, gec¸erlik ve gu¨venirli gi adolescent resilience: a framework for understanding healthy development in the face of risk discovering statistics using spss enhancing the resilience of nurses and midwives: pilot of a mindfulnessbased program for increased health, sense of coherence and decreased depression, anxiety and stress pozitif ve negatif duygu durum € olc¸e gi: gec¸erlik ve gu¨venirlik c¸alıs¸ması managing mental health challenges faced by healthcare workers during covid-19 pandemic human behavior theory: a resilience orientation multivariate data analysis briefing note on addressing mental health and psychosocial aspects of covid-19 outbreak-version 1 personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review statistical notes for clinical researchers: assessing normal distribution (2) using skewness and kurtosis principles and practice of structural equation modeling normal ve sorunlu ergenlerin yas¸am doyumu du¨zeyinin kars¸ılas¸tırılması [comparison of normal and problematic adolescents' life satisfaction level factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 the impact of covid-19 epidemic declaration on psychological consequences: a study on active weibo users progression of mental health services during the covid-19 outbreak in china factors influencing resilience of medical workers from other provinces to wuhan fighting against 2019 novel coronavirus pneumonia online mental health services in china during the covid-19 outbreak. the lancet infectious respiratory illnesses and their impact on healthcare workers: a review computer-assisted resilience training to prepare healthcare workers for pandemic influenza: a randomized trial of the optimal dose of training long-term psychological and occupational effects of providing hospital healthcare during sars outbreak immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers coping with covid-19: urgent need for building resilience through cognitive behaviour therapy managing healthcare workers' stress associated with the covid-19 virus outbreak stress and coping in the time of covid-19: pathways to resilience and recovery preserving mental health and resilience in frontline healthcare workers during covid-19 mental health status and coping strategy of medical workers in china during the covid-19 outbreak the brief resilience scale: assessing the ability to bounce back covid-19: emerging compassion, courage and resilience in the face of misinformation and adversity using multivariate statistics severe acute respiratory syndrome (sars) in hong kong in 2003: stress and psychological impact among frontline healthcare workers psychological impact of the covid-19 pandemic on health care workers in singapore resilient individuals use positive emotions to bounce back from negative emotional experiences immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china development and validation of brief measures of positive and negative affect: the panas scales statement on the second meeting of the international health regulations (2005) emergency committee regarding the outbreak of novel coronavirus (2019-ncov the multidimensional scale of perceived social support author biographies faruk bozda g works as a researcher at _ istanbul university-cerrahpas¸a at guidance and psychological counseling his research interests include social psychology, addiction, school psychology and identity key: cord-323482-kk8iyavj authors: muller, researcher ashley elizabeth; hafstad, senior advisor elisabet vivianne; himmels, senior advisor jan peter william; smedslund, senior researcher geir; flottorp, research director signe; stensland, researcher synne øien; stroobants, scientific coordinator stijn; van de velde, researcher stijn; elisabeth vist, senior researcher gunn title: the mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: a rapid systematic review date: 2020-09-01 journal: psychiatry res doi: 10.1016/j.psychres.2020.113441 sha: doc_id: 323482 cord_uid: kk8iyavj the covid-19 pandemic has heavily burdened healthcare systems throughout the world. we performed a rapid systematic review to identify, assess and summarize research on the mental health impact of the covid-19 pandemic on hcws (healthcare workers). we utilized the norwegian institute of public health's live map of covid-19 evidence on 11 may and included 59 studies. six reported on implementing interventions, but none reported on effects of the interventions. hcws reported low interest in professional help, and greater reliance on social support and contact. exposure to covid-19 was the most commonly reported correlate of mental health problems, followed by female gender, and worry about infection or about infecting others. social support correlated with less mental health problems. hcws reported anxiety, depression, sleep problems, and distress during the covid-19 pandemic. we assessed the certainty of the estimates of prevalence of these symptoms as very low using grade. most studies did not report comparative data on mental health symptoms before the pandemic or in the general population. there seems to be a mismatch between risk factors for adverse mental health outcomes among hcws in the current pandemic, their needs and preferences, and the individual psychopathology focus of current interventions. the covid-19 pandemic has heavily burdened, and in many cases overwhelmed, healthcare systems 1 ,2 including healthcare workers. the who emphasized the extremely high burden on healthcare workers, and called for action to address the immediate needs and measures needed to save lives and prevent a serious impact on physical and mental health of healthcare workers 3 . previous viral outbreaks have shown that frontline and non-frontline healthcare workers are at increased risk of infection and other adverse physical health outcomes 4 . furthermore, healthcare workers reported mental health problems putatively associated with' occupational activities during and up until years after epidemics, including symptoms of post-traumatic stress, burnout, depression and anxiety [5] [6] [7] . likewise, reports of the mental toll on healthcare workers have persistently appeared during the current global health crisis [8] [9] [10] . several reviews have already been conducted on healthcare workers' mental health in the covid-19 pandemic, with search dates up to may 2020. pappa et al. 11 identified thirteen studies in a search on 17 april 2020 and pooled prevalence rates; they reported that more than one of every five healthcare workers suffered from anxiety and/or depression; nearly two in five reported insomnia. vindegaard & benros' 12 review, searching on 10 may 2020, identified twenty studies of healthcare workers in a subgroup analysis, and their narrative summary concluded that healthcare workers generally reported more anxiety, depression, and sleep problems compared with the general population. in the face of a prolonged crisis such as the pandemic, sustainability of the healthcare response fully relies on its ability to safeguard the health of responders: the healthcare workers 13 ,14 . yet, the recent findings of psychological distress among healthcare workers might indicate that the healthcare system is currently unable to effectively help the helpers. understanding the risks and mental health impact(s) that healthcare workers experience, and identifying possible interventions to address adverse effects, is invaluable. our main aim was to perform an updated and more comprehensive rapid systematic review to identify, assess and summarize available research on the mental health impact of the covid-19 pandemic on healthcare workers, including a) changes over time, b) prevalence of mental health problems and risk/resilience factors, c) strategies and resources used by healthcare providers to protect their own mental health, d) perceived need and preferences for interventions, and e) healthcare workers' understandings of their own mental health during the pandemic. our second aim was to describe the interventions assessed in the literature to prevent or reduce negative mental health impacts on healthcare workers who are at work during the covid-19 pandemic. we conducted a rapid systematic review according to the methods specified in our protocol, published on our institution's website 15 . we included any type of study about any type of healthcare worker during the covid-19 pandemic, with outcomes relating to their mental health. we extracted information about interventions aimed at preventing or reducing negative mental health impacts on healthcare workers; we were therefore interested in quantitative studies examining prevalence of problems and effects of interventions as well as qualitative studies examining experiences. we had no restrictions related to study design, methodological quality, or language. we identified relevant studies by searching the norwegian institute of public health's (niph's) live map of covid-19 evidence (https://www.fhi.no/en/qk/systematic-reviews-hta/map/) and database on 11 may 2020, as described in our protocol 15 . the live map and database contained 20,738 references screened for covid-19 relevance containing primary, secondary, or modelled data. two researchers independently categorized these references according to topic (seven main topics, 52 subordinate topics), population (41 available groups), study design, and publication type. we identified references categorized to the population "healthcare workers", and to the topic "experiences and perceptions, consequences; social, political, economic aspects". in addition, we identified references by searching (title/abstract) in the live map's database, using the keywords: emo*, psych*, stress*, anx*, depr*, mental*, sleep, worry, somatoform, and somatic symptom disorder. we screened all identified references specifically for the inclusion criteria for this systematic review. the protocol of the live map of covid-19 evidence describes the methodology of the map and database 16 the last included search for this review was conducted on 11 may 2020. the search strategy is presented in appendix 1. we developed a data extraction form to collect data on country and setting, participants, exposure to covid-19, intervention if relevant, and outcomes related to mental health. we extracted data on prevalence of mental health problems as well as correlates (i.e. risk/resilience factors); strategies implemented or accessed by healthcare worker to address their own mental health; perceived need and preferences related to interventions aimed at preventing or reducing negative mental health consequences; and experience and understandings of mental health and related interventions. one researcher (aem) extracted data and another checked her extraction. two researchers (aem, sf/gev) independently assessed the methodological quality of systematic reviews using the amstar tool 17 and of qualitative studies using the casp checklist 18 . one researcher (aem) assessed the quality of cross-sectional studies using either the jbi prevalence or the jbi cross-sectional analytical checklist, and longitudinal studies using the jibi cohort checklist 19 . results of these checklists are presented in appendix 2 in the standard risk of bias format. we summarized outcomes narratively. we describe interventions and outcomes based on the information provided in the studies. when studies presented prevalence rates out mental health outcomes in figures without numbers, we extracted numbers using an online software (https://apps.automeris.io/wpd/). we presented mean prevalence rates as box-and-whisker plots. we decided not to perform a quantitative summary of the associations between the various correlates and mental health factors, due to a combination of heterogeneity in assessment measures and lack of control groups, and an overarching lack of descriptions necessary to confirm sufficient homogeneity. our included studies not only varied greatly from one another, they most often did not report sufficient information regarding inclusion criteria, population, setting, and exposure to assess potential clinical heterogeneity. we graded the certainty of the evidence using the grade approach (grading of recommendations assessment, development, and evaluation 20 . fifty-nine studies were included. table 1 displays their summarized characteristics, while appendix 3 displays characteristics of the individual studies. a total of 54,707 participants were drawn from at least 34 separate countries across the studies (one study reported participants came from 91 countries, but did not specify these). the people's republic of china was the single most common setting (40 studies and 44,540 participants), followed by iran (four studies). setting was not applicable for the two systematic reviews and the review of online mental health surveys. the majority of studies (46) were cross-sectional surveys; two studies reported surveys administered twice over time; five were interview studies, of which three were analyzed qualitatively and two quantitatively; and four were other designs, including a case series and a study that searched within a database of existing online surveys. we also identified two systematic reviews 35 ,60 , which included five primary studies 8 ,29 ,42 ,44 ,69 . the studies reported on healthcare workers working in different settings: 42 studies reported on health care workers in hospitals, two studies were conducted in specialist health services outside hospitals, and three studies in other settings, while 21 studies did not specify the healthcare setting or only partially described multiple settings. no studies reported on nursing homes or primary care settings. in 40 studies, participants were frontline workers, while 26 studies reported on non-frontline workers. frontline or non-frontline activities were unclear in ten studies. six studies reported on interventions to reduce mental health problems. more than half of the studies included nurses (31) and/or doctors (33) . study sizes ranged from a case study with three participants to a survey of 11,118 participants. six studies reported on the implementation of interventions to prevent or reduce mental health problems caused by the covid-19 pandemic among healthcare workers. these interventions can be loosely divided into those targeting organizational structures, those facilitating team/collegial support, and those addressing individual complaints or strategies. two interventions involved organizational adjustments. the first intervention was reported on by two studies 28 ,37 . hong et al. 37 called it a "comprehensive psychological intervention" for frontline workers undergoing a mandatory two-week quarantine in a vocational resort, following two-to three-week hospital shifts. the quarantine itself was also described as part of the intervention, explicitly intended "to alleviate worries about the health of one's family". other elements included shortened shifts; involvement of the labor union to provide support to healthcare workers' families; and a telephone-based hotline that allowed healthcare workers to speak to trained psychiatrists or psychologists. this hotline had already been available to healthcare workers for four hours per week prior to the pandemic, but was made available for twelve hours, seven days a week. chen et al. 29 reported a second intervention that attempted to address individual complaints and facilitate collegial support. a telephone hotline was set up to provide immediate psychological support, along with a medical team that provided online courses to help healthcare workers handle psychological problems, and group-based activities to release stress. however, uptake was low, and when researchers conducted interviews with the healthcare workers to understand this, healthcare workers reported needing personal protective equipment and rest, not time with a psychologist. they also requested help addressing their patients' psychological distress. in response, the hospital developed more guidance on personal protective equipment, provided a rest space, and provided training on how to address patients' distress. schulte et al. 61 targeted collegial support and building individual strategies through one-hour video "support calls" for healthcare workers called in from their homes, to describe the impact of the pandemic on their lives, to reflect on their strengths, and to brainstorm coping strategies. this intervention was implemented as a response to the hospital redeploying pediatric staff to work as covid-19 frontline staff, and reorganizing pediatric space to accommodate more pediatric and adult covid-19 patients. none of the studies that implemented mental health interventions reported on the effects of the interventions on healthcare workers. the only data available to approximate the impact of the pandemic on the mental health of healthcare workers come from two longitudinal survey studies reporting on changes over time, both of low methodological quality. lv et al. 52 surveyed healthcare workers before and during the outbreak, reporting no further information about the timeline. the study included both those working on the frontline and those with unclear exposure to covid-19. however, it is unclear whether respondents were the same at both time points. the prevalence of anxiety, depression, and insomnia increased over time, whether mild, moderate, moderate to severe, or severe (see figure 2 ). during the outbreak, one out of every four healthcare workers reported at least mild anxiety, depression, or insomnia. ***insert figure 2 about here *** yuan et al. 73 and an increase in smoking and drinking for only 1%. the proportion reporting improvement was similar for fidgeting, fear, and feeling nervous and uneasy, and more improved in not thinking one can succeed and for a reduction in smoking and drinking. two cross-sectional studies reported healthcare workers' self-reported changes in mental health; both were also of low methodological quality due to insufficient reporting. in benham et al. 24 , twelve iranian psychiatry residents were re-deployed to work one frontline shift. half of the residents reported that they experienced more distress after this shift. abdessater et al. 21 ,22 studied 275 urology residents not working on the frontline. when asked to report the level of stress caused by covid-19, 56% reported a medium to high amount of stress, and the remaining reported none to low. less than 1% had initiated a psychiatric treatment during the pandemic. a third cross-sectional study 70 , also of low methodological quality, surveyed 60 healthcare workers in china in february, during the "outbreak period". a different cohort of 60 healthcare workers were surveyed in march, during the "non-epidemic outbreak period". the healthcare workers in to the second phase of the survey reported less symptoms of anxiety and depression, and higher health-related quality of life. twenty-nine studies reported prevalence data of mental health variables as proportions or percentages. (seventeen additional studies reported data as average scores on various instruments, and we did not extract this data.) we present box-and-whisker plots in figure 3 to show the distribution of anxiety, depression, distress, and sleeping problems among the healthcare workers investigated in the 29 studies, using the authors' own methods of assessing these outcomes the most commonly reported protective factor associated with reduced risk of mental health problems was having social support 48 ,58 ,69 ,74 . two studies directly measured self-perceived resilience. bohlken et al. 25 asked their sample of psychiatrists and neurologists to assess how resilient they were on a likert scale from 1-5 ("not applicable" to "completely applicable"), and 86% selected the two highest categories. cai et al. 27 compared experienced frontline workers with inexperienced frontline workers, and found that inexperienced workers scored lower on total resilience on the connor-david resilience scale as well as within each of three subscales, and had more mental health symptoms. inexperienced workers were also younger and had less social support available to them. ten studies reported that healthcare workers utilized other resources or had individual strategies to address their own mental health during the pandemic, separate from formal interventions. six studies reported that healthcare workers utilized support from family/friends during the pandemic. "family" was the most common stress coping mechanism utilized by louie et al. kang et al. 40 found slightly higher levels of interest in professional resources. when asked from whom they prefer to receive "psychological care" or "resources", 40% answered psychologists or psychiatrists, 14% answered family or relatives, 15% answered friends or colleagues, 2% answered others, and 30% said they did not need help. the authors found that the preferred sources of psychological resources were related to the level of psychological distress. in a structural equation model that uncovered clusters of healthcare workers with different distress levels (subthreshold, mild, moderate, and severe), those with moderate and severe distress more often preferred to receive care from psychologists or psychiatrists, while those with subthreshold and mild distress more often preferred to seek care from family or relatives. in two studies, participants specified that they had a greater need for personal protective equipment than for psychological help. chung et al. 32 reported this in a survey that allowed healthcare workers to describe their needs and concerns in free text and to request contact with a psychiatric nurse. while 3% requested such contact, nearly half of those who answered the free text question about their psychiatric needs wrote that they needed personal protective equpiment instead, and 20% said they were worried about infection. chen et al.'s 29 study was to understand why uptake of their psychological intervention was so low, and findings were identical to chung et al.'s: "many staff mentioned that they did not need a psychologist, but needed more rest without interruption and enough protective supplies" (p. e15). only one study explored how healthcare workers would be willing to provide mental health services to other healthcare workers: twelve psychiatry residents were re-deployed as frontline workers for one shift in benham et al.'s 24 study. after that shift, none were willing to provide face-to-face mental health services to other healthcare workers, although 75% said they would provide online services. they identified healthcare workers of deceased patients as possible target populations for online services. three qualitative studies assessed as valuable were included. two interconnected themes across all three studies were distress stemming both from concern for infecting family members, and from being aware of family members' concern for the healthcare workers. wu et al. 67 explored reasons for stress during interviews with healthcare workers at a psychiatric hospital. while these healthcare workers were not on the frontline, they felt they were at higher risk of exposure than healthcare workers at a general hospital. their wards were crowded, and several patients were admitted from emergency rooms with aggressive behaviors that made social distancing difficult or that posed direct challenges to healthcare workers' use of personal protective equipment (such as tearing masks). healthcare workers felt unprepared because psychiatric hospitals had no plans in place. at the same time, they also felt that their peers on the frontline were providing more valuable care. an additional source of stress was knowledge of their own risk of infection and transmission to family members, particular to elderly parents in their care, and to children who were at home and whose schoolwork had to additionally be managed. the disruption of the pandemic to nurses' personal lives and career plans was another stressor. sun et al. 65 concern was great enough that several respondents did not tell their family they were working on the frontline, while others did not live at home during this period. as with wu et al.'s 67 nonfrontline workers, these healthcare workers also reported fear and anxiety of a new infectious disease that they felt unprepared to handle on a hospital-level, unprepared to treat on a patientlevel, and from which they were unable to protect themselves. the first week of training and the first week of actual frontline work was characterized by these negative emotions, which were then joinednot necessarily replacedby more positive emotions such as pride at being a frontline nurse, confidence in the hospital's capacity, and recognition by the hospital. yin et al. 72 families, particularly because their families would suffer more financially from needing to be quarantined than they already were suffering under the lockdown; fears of using personal protective equipment incorrectly; and feeling unequipped to handle patients' non-medical needs. healthcare workers reported that stigma suppressed patients' provision of accurate travel and quarantine history. this was an issue they were ill-equipped to help patients address when they returned to the community. healthcare workers also reported that they were stigmatized, because they were potential sources of infection. this systematic review identified 59 heterogeneous studiesincluding three qualitative, fifty quantitative, two narrative reviews, and four other designsthat examined the mental health of between one and two of every five healthcare worker reported anxiety, depression, distress, and/or sleep problems. only one study reported on somatic symptoms such as changes in appetite. our confidence in these broad estimates, assessed using grade, was very low, which leads us to caution that the true prevalence of anxiety, depression, distress, and sleep problems among healthcare workers are likely different than our estimates. at the same time, is also common in interventions for healthcare worker burn-out before the pandemic 83 . the most striking illustration of this was the finding shared by two studies 29 ,32 that healthcare workers said personal protective equipment would benefit their mental health more than professional help. on the other hand, it is possible that healthcare workers could benefit from professional mental health interventions more than they recognize or report, and that under-recognition is related to occupational culture, or fear of stigma or being perceived as weak 84 . while a variety of countries were represented, four of every five participants were chinese, and chinese occupational culture may be a salient mediator of healthcare workers' expressed preferences 85 , although this must be explored further. health's rigorous methodological standards for systematic reviews, such as two researchers screening and assessing eligibility. an additional methodological strength is our utilization of the live map of covid-19 evidence, one of the first reviews to do so (see also two reports 88 ,89 and one diagnostic accuracy study 90 ). by using our map, we quickly identified 871 studies that had already been categorized to our topic and population of interest, without having to search in academic databases and screen again. while not being able to conduct a meta-analysis is unfortunate, it was appropriate not to assume that poorly reported studies were homogenous enough. the principle of homogeneity tends to be overlooked by systematic reviewers eager to produce a summary estimate, but if met, means that all studies included were similar enough that their participants can be considered participants of one large study 91 . the result, however, is that the prevalence data about mental health problems does not provide a summary estimate that can be generalized. other weaknesses are those common to rapid reviews due to time pressure, such as fewer details about the included studies' populations being presented than normally reported. the covid-19 pandemic has resulted in a flood of studies, many of which have been pushed through the peer-review process and published at speeds hitherto unseen (see glasziou 92 for a discussion). it is therefore not surprising that the majority of our included 59 studies were assessed as having a high risk of bias or being of low methodological quality. lack of information on samples or procedures was a common limitation, leading to serious implications to the generalizability and validity of findings. we also call on journals and researchers to balance the need for rapid publication with properly conducted studies, reviews and guidelines 93 . healthcare workers in a variety of fields, positions, and exposure risks are reporting anxiety, depression, distress, and sleep problems during the covid-19 pandemic. causes vary, but for those on the frontline in particular, a lack of opportunity to adequately rest and sleep is likely related to extremely high burdens of work, and a lack of personal protective equipment or training may exacerbate mental health impacts. provision of appropriate personal protective equipment and work rotation schedules to enable adequate rest in the face of long-lasting disasters such as the covid-19 pandemic seem paramount. over time, many more healthcare workers may struggle with mental health and somatic complaints. the six studies exploring mental health interventions mainly focused on individual approaches, most often requiring healthcare workers to initiate contact. proactive organizational approaches could be less stigmatizing and more effective, and generating evidence on the efficacy of interventions/strategies of either nature is needed. as the design of most studies was poor, reflecting the urgency of the pandemic, there is also a need to incorporate high-quality research in pandemic preparedness planning. the authors report no conflicts of interest. the protocol for this review is available online. no funding was received. the italian health system and the covid-19 challenge critical care crisis and some recommendations during the covid-19 epidemic in china covid 19 public health emergency of international concern (pheic) global research and innovation forum: towards a research roadmap mers and covid-19 among healthcare workers: a narrative review prevalence of psychiatric disorders among toronto hospital workers one to two years after the sars outbreak long-term psychological and occupational effects of providing hospital healthcare during sars outbreak mental health of nurses working at a governmentdesignated hospital during a mers-cov outbreak: a cross-sectional study mental health survey of 230 medical staff in a tertiary infectious disease hospital for covid-19 covid-19 pandemic and its impact on mental health of healthcare professionals the experiences of health-care providers during the covid-19 crisis in china: a qualitative study prevalence of depression, anxiety, and insomnia among healthcare workers during the covid-19 pandemic: a systematic review and meta-analysis covid-19 pandemic and mental health consequences: systematic review of the current evidence covid-19 and italy: what next? protect our healthcare workers the impact of the covid-19 pandemic on mental health of health care workers: protocol for a rapid systematic review a systematic and living evidence map on covid-19 amstar 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both casp checklist for qualitative research grade guidelines: 1. introduction-grade evidence profiles and summary of findings tables covid19 pandemic impacts on anxiety of french urologist in training: outcomes from a national survey covid-19 outbreak situation and its psychological impact among surgeon in training in france fear and practice modifications among dentists to combat novel coronavirus disease (covid-19) outbreak working in the emergency and inpatient covid-19 special wards: a different experience for iranian psychiatric trainees amid the outbreak: running title: experience of iranian psychiatric trainees in covid-19 special wards psychological impact and coping strategies of frontline medical staff in hunan between a cross-sectional study on mental health among health care workers during the outbreak of corona virus disease a study of basic needs and psychological wellbeing of medical workers in the fever clinic of a tertiary general hospital in beijing during the covid-19 outbreak mental health care for medical staff in china during the covid-19 outbreak. the lancet psychiatry prevalence of self-reported depression and anxiety among pediatric medical staff members during the covid-19 outbreak in guiyang, china multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid-19 outbreak staff mental health self-assessment during the covid-19 outbreak psychological impact of the covid-19 pandemic on adults and their children in italy covid-19 and paediatric health services: a survey of paediatric physicians in australia and new zealand covid-19 associated psychiatric symptoms in healthcare workers: viewpoint from internal medicine and psychiatry residents psychological effects of covid-19 on hospital staff: a national cross-sectional survey of china mainland the stress and psychological impact of the covid-19 outbreak on medical workers at the fever clinic of a tertiary general hospital in beijing: a cross-sectional study assessment of the mental health of front line healthcare workers in a covid-19 epidemic epicenter of china psychological crisis intervention during the outbreak period of new coronavirus pneumonia from experience in shanghai impact on mental health and perceptions of psychological care among medical and nursing staff in wuhan during the 2019 novel coronavirus disease outbreak: a cross-sectional study covid-19-related information sources and psychological well-being: an online survey study in taiwan factors associated with mental health outcomes among health care workers exposed to coronavirus disease psychological impact on women health workers involved in covid-19 outbreak in wuhan: a cross-sectional study vicarious traumatization in the general public, members, and nonmembers of medical teams aiding in covid-19 control screening for chinese medical staff mental health by sds and sas during the outbreak of covid-19 psychological impact and predisposing factors of the coronavirus disease 2019 (covid-19) pandemic on general public in china online mental health services in china during the covid-19 outbreak. the lancet psychiatry perceived social support and its impact on psychological status and quality of life of medical staffs after outbreak of sars-cov-2 pneumonia: a cross-sectional study mental health status of doctors and nurses during covid-19 epidemic in china the impact of covid-19 pandemic on spine surgeons worldwide psychological status of medical workforce during the covid-19 pandemic: a cross-sectional study anxiety and depression survey of chinese medical staff before and during covid-19 defense brief psychotic disorder triggered by fear of coronavirus? work stress among chinese nurses to support wuhan for fighting against the covid-19 epidemic issues relevant to mental health promotion in frontline health care providers managing quarantined/isolated covid19 patients evaluation of the level of anxiety among iranian multiple sclerosis fellowships during the outbreak of covid-19 assessment of iranian nurses′ knowledge and anxiety toward covid-19 during the current outbreak in iran mental health, risk factors, and social media use during the covid-19 epidemic and cordon sanitaire among the community and health professionals in wuhan investigation and analysis of the psychological status of the clinical nurses in a class a hospital facing the novel coronavirus pneumonia covid-19 and mental health: a review of the existing literature addressing faculty emotional responses during the covid19 pandemic psychological stress of icu nurses in the time of covid-19 emergency responses to covid-19 outbreak: experiences and lessons from a general hospital in nanjing novel coronavirus and related public health interventions are negatively impacting mental health services a qualitative study on the psychological experience of caregivers of covid-19 patients psychological impact of the covid-19 pandemic on health care workers in singapore stressors of nurses in psychiatric hospitals during the covid-19 outbreak psychological stress of medical staffs during outbreak of covid-19 and adjustment strategy 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 psychological status of surgical staff during the covid-19 outbreak symptom cluster of icu nurses treating covid-19 pneumonia patients in wuhan a study on the psychological needs of nurses caring for patients with coronavirus disease 2019 from the perspective of the existence, relatedness, and growth theory comparison of the indicators of psychological stress in the population of hubei province and non-endemic provinces in china during two weeks during the coronavirus disease 2019 (covid-19) outbreak in february 2020 survey of insomnia and related social psychological factors among medical staffs involved with the 2019 novel coronavirus disease outbreak at the height of the storm: healthcare staff's health conditions and job satisfaction and their associated predictors during the epidemic peak of covid-19 mental health and psychosocial problems of medical health workers during the covid-19 epidemic in china prevalence and influencing factors of anxiety and depression symptoms in the first-line medical staff fighting against the covid-19 in gansu the immediate mental health impacts of the covid-19 pandemic among people with or without quarantine managements impact of coronavirus syndromes on physical and mental health of health care workers: systematic review and meta-analysis the sleep-deprived human brain job decision latitude, job demands, and cardiovascular disease: a prospective study of swedish men health workforce burn-out systematic literature review of psychological interventions for first responders stigmatizing attitudes towards mental disorders among non-mental health professionals in six general hospitals in hunan province occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis factors affecting mental health of health care workers during coronavirus disease outbreaks: a rapid systematic review should healthcare personnel in nursing homes without respiratory symptoms wear facemasks for primary prevention of covid-19? -a rapid review social and economic vulnerable groups during the covid-19 pandemic antibody tests for identification of current and past infection with sars-cov-2 mixed and indirect treatment comparisons. evidence synthesis for decision making in healthcare waste in covid-19 research using grade in situations of emergencies and urgencies: certainty in evidence and recommendations matters during the covid-19 pandemic, now more than ever and no matter what key: cord-102542-1mglhh41 authors: jovanovi'c, mladjan; baez, marcos; casati, fabio title: chatbots as conversational healthcare services date: 2020-11-08 journal: nan doi: 10.1109/mic.2020.3037151 sha: doc_id: 102542 cord_uid: 1mglhh41 chatbots are emerging as a promising platform for accessing and delivering healthcare services. the evidence is in the growing number of publicly available chatbots aiming at taking an active role in the provision of prevention, diagnosis, and treatment services. this article takes a closer look at how these emerging chatbots address design aspects relevant to healthcare service provision, emphasizing the human-ai interaction aspects and the transparency in ai automation and decision making. ⬛ conversational systems are entering our everyday lives, such as amazon alexa and google assistant. beyond such all-in-one systems, there are growing demands for building conversational services in healthcare. the services are using a shared design metaphor -a personal assistant that provides healthcare through natural conversation. the main reason is making online healthcare more user-friendly -an agent takes a patient through a turntaking dialog, similar to how doctors do [1] , [2] . the recent transformation of digital healthcare aims at providing personalized health services and helping patients in self-managing their conditions [1] . chatbots are becoming part of this paradigm shift as a cost-effective means to deliver such services [1] . besides, they facilitate well-being as ingraining positive self-care habits [1] . the main benefits are ease of use and accessibility -the conversation metaphor makes them more intuitive, available on smartphones everywhere, anytime [3] . however, healthcare provision still depends on health professionals. therefore, inspiring researchers and practitioners to explore the potential of conversational ai to bring personalized services through automation [1] . the growing number of healthcare chatbots, partly due to the democratization of chatbot development, motivates a closer look at how the systems address aspects concerning user experience, adoption and trust in automation, and healthcare provision. while a recent literature review provides insights on general design considerations for healthcare chatbots [4] , we focus on publicly available chatbots and take a more domain-specific approach in identifying relevant design dimensions considering the specific role in healthcare provision. we report on a systematic analysis of 158 publicly available healthcare chatbots. due to their very nature, we believe that the form and function of the healthcare chatbots cannot be neatly separated and are equally important. this paper: • identifies salient service provision archetypes that characterize the emerging roles and functions the chatbots aim to fulfill; • assesses the design choices concerning domainspecific dimensions associated with health service provision and user experience; • provides implications for theory and practice that highlight existing gaps. a healthcare chatbot can be conceptualized as a set of interconnected layers. the knowledge layer contains the domain and user databases. the information from this layer is an input for the service layer of healthcare provision. this layer implements healthcare decision-making processes. once it generates the decisions, they are communicated to a dialog layer. the rule-matching dialogs are robust and straightforward to build but work in a constrained domain, whereas probabilistic (machine learning) tools may provide more natural dialog but lack robustness [5] . the dialog layer extracts user intentions, creates responses by consulting the service layer, and communicates them to the presentation layer that implements a text-or voice-based ui. we introduce the analytical framework containing the attributes to characterize and compare existing healthcare chatbots. the framework captures the domain-specific aspects of healthcare provision, emphasizing the human-ai interaction aspects and the transparency in ai automation and decision making. the dimensions are summarized below and detailed in table 1: • conversational style. while deploying suitable and successful dialog strategies is still an open challenge in human-ai interactions, some domain-specific dimensions emerge from research in health information systems [6] and recent general guidelines for human-ai interaction [7] . sociability, empathy, understandable medical vocabulary, and emerging dialog styles are among the key design dimensions we analyze. • understanding users. the users' ability to express intentions and be understood by the chatbots is another fundamental challenge in dialog-based interactions. data collection methods (explicit or implicit) and the ability to recover from conversation breakdowns are among the critical functions of healthcare, shaping user's expectations of natural dialog capabilities. • accountability. there are ethical and practical reasons for making ai more transparent and explainable. not only concerning model biases and privacy concerns but also to understand the reasoning behind algorithmic decisions that could have a significant impact on healthcare service provisioning [8] . the implementation of these features can address privacy concerns, build trust, and make the service provisioning more accountable for users [8] . • healthcare provision. the domain-specific aspects of service provisioning include the type of the chatbots' role, emerging functional archetypes within these roles, collaboration facilitated by the chatbot, and continuity of service delivery. using the analytical framework, we identified and characterized publicly available healthcare chatbots in the english language, as of august 2020. starting from the health provisioning roles, we analyzed how the other chatbot design dimensions are implemented for the primary functions. to this end, we screened health-related chatbots from two popular databases, botlist (https://botlist.co) and chatbots.org (https://chatbots.org) in the categories "health and fitness" and "body health". we included other available, well-known examples that are often analyzed in the scientific literature and appear at the top search results when searching for chatbots for health. our list is a representative sample with a clear overview of the chatbots' use. a total of 225 chatbots were screened and annotated by health provisioning roles by two researchers, resulting in 158 relevant health chatbots (coding agreement 90%). two researchers independently annotated the chatbots' functions in an emergent coding scheme, which was then consolidated by consensus to describe the salient archetypes for each role. the analysis focused on archetypes that describe a direct involvement of the chatbot in the healthcare service provisioning, emulating the functions of a healthcare professional (e.g., in performing a diagnosis, or delivering a therapy). it was the case for the 6 of the 9 archetypes identified. we excluded chatbots from the archetypes "support for diagnosis", "access to healthcare" and "support for therapy", where chatbots act as mediators to facilitate access to healthcare services, information and products. accordingly, we had around 7-8 top chatbots from 6 archetypes, for a total of 45 chatbots. we selected popularity (e.g., number of views and likes) as a measure of quality and adoption, thus focu[9] , a premise of the effectiveness of a health intervention. as a property (content) of the conversation itself, it builds and maintains social bonds among interactants [10] . in this regard, we look at whether chatbots implement social conversation capabilities. empathy. another desirable characteristic of chatbots is exposing empathy, the ability to recognize users' emotions and respond appropriately to the current mood [1] , [3] , [9] , [11] , and even more so in vulnerable scenarios posed by health services. thus, we qualitatively assess if chatbot dialogs provide empathy cues in their conversations. vocabulary. adapting the conversation content to a suitable and understandable medical vocabulary is also important for the quality of the healthcare provision [1] . we analyze strategies and features adopted by chatbots to address this aspect explicitly. proactivity. a mix of proactive and reactive behavior is another inherent feature of everyday human communication that ai aims to replicate [7] , and that can inform how services are provided. we examine whether chatbots display proactive behaviors in providing their services. understanding users data collection. an important aspect is understanding the input patterns and data collection methods enabled by chatbots as they inevitably balance the robustness and naturalness of conversations [5] . in this regard, we qualitatively assess emerging input patterns, and determine whether the chatbots leverage on explicit and implicit data collection strategies. error recovery. error recovery strategies are crucial for addressing the breakdowns and preventing from degrading the user experience and drawing incorrect decisions [12] . we assess whether chatbots implement error recovery strategies, focusing on the ability to deal with human error. explainability. we define explainability as the ability of the chatbot to inform and explain its decisions (e.g., how a diagnosis was reached, or why an activity program was changed). transparency. we look at the transparency with regard to data collection practices (e.g., why is the chatbot collecting certain information). role. it indicates the chatbot's role(s) in healthcare provision as diagnosis, prevention, and therapy. some chatbots may play multiple roles. archetype. it describes emerging service patterns within the health provision role. collaboration. together with proper integration with healthcare infrastructure as a means for augmenting skills of medical professionals [3] . when analyzing collaboration, we focus on identifying the stakeholders involved and the type of technology-mediated interactions enabled by the chatbot. continuity. refers to the time of the service delivery, whether in one-time sessions (akin short-term visits) or leveraging on the opportunity for more continuous healthcare delivery [1] , [2] . sing the analysis on the most widely adopted chatbots. a scoring system was derived to complement the qualitative observations, and describe the level of implementation of each dimension: low, indicating that the dimension was not explicitly addressed (e.g., explainability: the chatbot does not provide any explanations for its decisions); medium, showing partial implementation (e.g., explainability: the it professional chatbot provides some evidence, but important details are still missing); high, meaning a high degree of implementation (e.g., explainability: the chatbot explains major decisions). the supplementary material including details about the process, scoring system, dialog examples and resulting annotated dataset is available at https://cutt.ly/tdozkpm. we detail our analysis in the following sections, describing the emerging archetypes and salient design features as characterized by our framework. diagnostic chatbots check user's symptoms and recommend courses of action. three general archetypes of diagnosis chatbots emerged from our analysis: • support for diagnosis (10/32). the archetype does not perform the diagnosis but instead support a diagnosis by either i) facilitating access to health services, such as the pathology lab chatbot facilitating access to doctors and scheduling visits, ii) supporting online consultations with health professionals, such as the icliniq that pairs up users with doctors for online consultation, and iii) providing conversational access to information regarding symptoms and diseases, such as the webmd. • general symptom checker (15/32). the archetype is mimicking a consultation with a general health professional, walking users through a series of questions regarding their symptoms to diagnose a condition, and, in some cases, suggests a course of action. a prominent example is healthtap, a chatbot that collects symptoms and provides potential causes in dialog-based interactions. • specific symptom checker (7/32). this archetype aims at either i) helping users confirm the presence and severity of an ailment, or ii) diagnosing a particular condition, akin to having a consultation with a medical specialist. an example from the first category is feverbot, which helps users determine whether they require medical attention, and for the second, the mental care bot, which specializes in diagnosing mental disorders. the archetypes have different foci but follow a typical dialog structure, consisting of profiling the user, collecting and refining symptoms, diagnosis, and follow-up. this process is typically enacted in onetime sessions involving a user and the chatbot, not reusing previously collected information -even though some chatbots offer symptoms journaling (e.g., healthtap). collecting and refining symptoms is approached with different dialog styles. specifying symptoms in natural language (e.g., "i have back pain") has varying levels of success. the chatbots try to identify the symptom either directly from the user input (e.g, your.md), directing the user input to a search page (e.g., babylonheath), or a combination of both. follow-up questions to refine the symptoms (e.g., "which part of your back is hurting") display a closed list of predefined options (e.g., "lower back" or "upper buttock area") requiring users to select an option from a list (e.g., ada), or swiping through illustrated cards (e.g., healthtap). the symptom checkers for skin problems (e.g., skinive) have the possibility of uploading pictures to bootstrap the diagnosis, using computer vision to interpret the input. interestingly, none of the chatbots make use of implicit data collection (e.g., sensor data), but collect user information explicitly during the conversations. allowing users to edit and backtrack information is an error recovery mechanism absent in almost half of the chatbots (e.g., buoyhealth provides an "edit" option on each user input). the majority of chatbots interact with users following a scripted interview without being cautious of the users' responses. making technical language understandable is a strategy implemented explicitly by only three chatbots. they address this aspect by either including contextual help for each question (e.g., ada: "what does it mean"), presenting pictures of the symptoms and options (e.g., healthtap), and indirectly by requesting feedback on questions (e.g., buoyhealth: "this is confusing"). transparency clarifies potential privacy concerns regarding sensitive questions. despite its importance, only one chatbot explicitly addressed this issue, namely buoyhealth, allowing users to inquire about the reasons behind each question ("why am i being asked this?"). the typical diagnosis report is a list of potential causes, explaining the reasoning behind and courses of action. it consists of the information describing: i) strength of the evidence supporting the diagnosis, ii) symptoms present for the cause, iii) type of care recommended and the specialist needed, and iv) possible actions. except for three chatbots, the majority explains their decisions by providing evidence connecting reported symptoms to the potential causes. all chatbots explicitly inform users that the report does not replace a medical consultation. the chatbots in this role assist in tracking and building awareness of a user's health and help prevent health declines by building desirable habits. the prevention is offered through a range of services [1] that can be aggregated into three archetypes: • access to healthcare (12/109). the chatbots from this archetype do not participate in the provision of healthcare service but represent an entry point to using these services. its main goal is to increase the efficiency of healthcare services by reducing the effort and increasing the speed of access. they do this by i) connecting patients to healthcare professionals, ii) discovering medical drugs online, or iii) providing healthcare customer service tasks. for example, the iclinic provides 24/7 medical customer service for patients, such as booking appointments with their doctors. the project alta facilitates the discovery and purchase of pills for improving cognitive functions. • health education (20/109). the educational archetypes prevent by teaching users on prevention procedures for specific health conditions. for instance, doctorbot provides healthcare information on different topics. a very recent example is jennifer, a chatbot designed to combat misinformation and answer questions on the covid-19 virus. • health coaching (77/109). its goal is to prevent health degradation by improving general wellbeing and inducing a healthy lifestyle. at its core are psychological incentives to maintain or facilitate desirable behaviors. their functions can be categorized as i) personalized reminders for mental exercise and workouts, ii) psychological motivators for mental and physical practices, or iii) advisors on positive habits regarding sleep, nutrition, and well-being. for example, the fitcircle uses reputation-based incentives for exercising (such as goal-setting and progress information), while the stopbreathe&think recommends mental exercise for psychological well-being. the forksy is a nutrition assistant who advises on nutriments tailored to the user's health goals and eating habits. concerning conversational style, the first archetype specializes in a specific task, such as connecting with a doctor, booking an appointment, or ordering particular medicine. the latter two are flexible in a sense that they educate on related, but different topics, or coach on a range of well-being activities within a type or across several types (physical, mental, nutritional). all archetypes offer instrumental, goaloriented conversations in which they guide users through predefined programs of exercises. regarding the vocabulary, less than half the chatbots referred the users to external glossaries of terms for additional explanations. the archetypes employ proactive conversation during prevention, by probing users for necessary information. the user information is collected explicitly, from the conversations. the error recovery is present as either asking the users to rephrase the misunderstood input or jumping to the beginning of the dialogs. regarding accountability, the archetypes do little to explain the specific decision to the users (e.g., general explanations on their websites). the transparency with the archetypes is low in the sense of not highlighting nor clarifying the reasons for collecting data from their users. the chatbots from the first archetype follow a scripted, question-answering dialog flow without keeping conversation history. for example, healthy recipe hq implements on-demand, dynamic question answering by aggregating available information online. the second archetype implements a similar dialog structure while educating on a specific topic. the third archetype offers a more complex dialog with flexible conversation based on the history and user profiling. health coaching chatbots recommend actions based on user monitoring through sustained conversation. the actions originate from activities' pools including workouts, nutrition plans, and mental exercise programs. they continuously motivate users for a healthy lifestyle by combining psychological incentives that include self-reflection on achieved progress, reminders for activities, and the evidence it professional from peers. some health coaching chatbots connect with peers, such as fitwell. otherwise, the majority targets individuals. the role assists or provides treatment of specific health declines or conditions (such as pregnancy or therapeutic diet). the therapy services can be grouped into the following archetypes: • support for therapy (7/41) . this archetype assists during the phases of the treatment. the examples are personalized reminders to medication adherence as part of the therapy (e.g., florence), or listing medicines based on positive online user reviews for natural health cures (e.g., healthrobot). • health therapy (20/41). the therapist archetype takes a more active role by providing at-home therapy for its patients. based on their primary target, they offer either i) drug-based therapy or ii) practice-based therapy for its patients. the first sub-archetype recommends and tracks medicine use during the treatment (such as florence). the second sub-archetype provides practical guidance on the activities for successful treatment. for instance, ketobot suggests a ketogenic diet to fight against diabetes. this archetype provides a range of therapies that target specific mental states and emotions. the therapy is a structured, guided conversation that starts with a question-answering to identify the patients' condition. it continues by recommending specific exercises based on the estimated conditions and tracking the target state. the measures of treatment's progress are self-reported, provided by patients as a freeform text. woebot is a personalized mental therapist who tracks users' mood and suggests mental activities. wysa aims at improving patients' mental health by providing emotional support. the common goal is to build resilience to mental disorders (i.e., stress, depression and anxiety) by developing positive habits (i.e., selfawareness and optimism). the archetypes support multiple activities (i.e., facilitating access to different types of medicines) or health conditions (i.e., aiming at various health conditions). the cbt archetypes try to understand and respond to the users' current mood. this aspect is entangled with social elements, such as engaging in small talk on non-treatment topics. it increases the amount of conversation, specifically user-provided data, to improve the accuracy of guessing the user's emotions. as for the therapy-specific terms, the chatbots offer explanations during the conversations. the first archetype induces conversations through personalized reminders, whereas cbt chatbots initiate the dialogs on a time basis. the error recovery strategies include restarting current conversation, or asking additional questions for mutual understanding. user data are collected explicitly, from user input during conversations. concerning accountability, the minority of the therapy chatbots explain their decision to users, and clarify the reasons for collecting specific user data. the supportive archetype uses rule-based or statistical approaches to dialog management. the former follows a predesigned turn-taking conversation (i.e., meditation master to alleviate stress and sleeplessness). the latter implements a more natural back-and-forth message exchange that uses context information to generate responses. the second archetype employs flexible, probabilistic dialogs that preserve the conversation context. it follows a conversation pattern in which patients are screened for their condition(s), and guided and monitored throughout the specific treatment. the dialog adapts to the treatment's progress. the third archetype follows a similar principle. the context information is extracted from user profiling and conversation history (i.e., wysa in monitoring therapy progress). it focuses on multiple mental/emotional states and conversation as a means of therapy, offering more fluid dialogs (i.e., woebot). archetypes mainly target individual users. current healthcare chatbots remain a supplementary service rather than a replacement of the medical professionals. the archetypes share levels of engagement as i) an active role in healthcare provision, emulating the functions of a healthcare professional; ii) facilitating access to healthcare services by matching users with service providers, or supporting the service delivery; and iii) providing users with information and products. some chatbots expose multiple roles. for example, florence instructs medicine intake during therapy, and provides information about a disease, for prevention. our findings confirm the existing evidence that a practical, task-oriented goal conversation is dominant with healthcare chatbots [1] , [2] . except for the cbt archetype, chatbots do little to understand human social and emotional cues. concerning the use of medical vocabulary, our analysis revealed that the diagnostic and preventative chatbots use expert vocabulary in healthcare provisions and should improve on making the terminology understandable to their users. as for the dialog initiative, preventative and therapeutic archetypes are more proactive than diagnostic archetypes that react to the users' questions. future healthcare chatbots should improve the conversation's social and emotional aspects while adapting to users' health literacy. the lack of these aspects may create dissonance in user experience due to false expectations and lead to rejection [9] , [11] , [13] . understanding users. the chatbots' natural language capabilities remain limited, leading to alternatives such as breaking down the dialog in multiple questions and constraining user choices to it professional deal with this limitation. this is particularly the case in diagnosis chatbots or data collection tasks where the user cannot narrate their condition but instead is guided through questions. preventative and therapeutic chatbots offer more fluent dialogs by learning about their users and reusing conversation context. in analyzing the chatbots, we also noticed repair strategies [14] not implemented correctly in the dialog, sometimes even in its most basic form, such as preventing users from modifying previous inputs. another aspect we noticed is that the archetypes rely mostly on explicit user input from conversations. the exception are chatbots that accept pictures of affected skin areas for automatic processing. the above reveals that restricting interaction through close-ended questions may expand the chatbot's understand of the users, but errors related to human input or incorrect references can still emerge in interactions. improving error management is the emerging requirement for health chatbots. as for opportunities, chatbots can significantly benefit from continuous implicit data collection using smart devices' sensing technologies currently widespread [15] . accountability. we discovered that transparency in data collection is insufficient in the archetypes. the minority of the analyzed chatbots give reasons for asking users for their data (figure 1 ). concerning explainability, the chatbots do little to provide causes or explain the reasons behind their healthcare decisions. these can raise concerns with users about chatbots' accountability. the implications are two-fold. firstly, public expectations of the chatbots need to be set explicitly, in advance. secondly, there is a need for greater transparency and explainability of the logic behind each archetype. in particular, i) explaining why and how the chatbot collects certain information, and ii) clarifying all the relevant decisions taken during the service provision (e.g., why diagnosing an illness, prescribing a drug, or increasing the workout intensity). healthcare provision. traditionally, the patient's condition is assessed during sporadic, short-term visits to healthcare facilities, and critical decisions may be affected by the uncertainty of the measurements. we observed that not many chatbots capitalize on the opportunities for continuity in the service provisioning. diagnostic chatbots provide one-time sessions with little to no information shared across sessions. therapeutic and health coaching archetypes offer prolonged, shared interactions with patients at their homes. currently, healthcare chatbots are standalone applications, independent of healthcare systems. concerning collaboration, the archetypes focus on individuals as a user-chatbot relation. group dynamics are missing, supported by a handful of chatbots as user-chatbot-doctor relations (i.e., sensely), or forming peer groups (i.e., fitwell). the chatbots need to address the above aspects through continuous service and better integration, opportunities not entirely leveraged by current healthcare systems [1] , [2] . the future healthcare chatbots should also engage and moderate among multiple actors consisting of patients, their social circles (family and friends), and caregivers. this assumes reusing social context by leveraging the humans and intelligent agents, the environment, and the healthcare infrastructure [16] . healthcare chatbots are yet to capitalize on the opportunities provided by conversational media to provide better dialog-based interactions appropriate to the task, and with the social intelligence to manage interaction in potentially vulnerable scenarios. our work provides the first step towards these goals by characterizing the emerging roles of chatbots in service provisioning and highlighting design aspects that require the community's attention. we believe our findings can guide researchers in identifying and validating dialog patterns appropriate to the existing archetypes, and practitioners in understanding the emerging use cases of chatbots in healthcare provision. future work should focus on understanding the actual medical value of the chatbots and their effects on health outcomes and user experience. our study does not attempt to evaluate an exhaustive list of existing health chatbots, but a representative sample of the current landscape. we acknowledge that the popularity metric used for selecting chatbots for full evaluation is an approximation, but given the number of chatbots evaluated any potential misrepresentation should be alleviated. the evaluation did not address the effects of chatbots on health outcomes or the evidence supporting the health service. similarly, we did not analyze the content, nor assess it for accurate and evidence-based information. they are important aspects to be addressed in future work. survey of conversational agents in health delivering cognitive behavior therapy to young adults with symptoms of depression and anxiety using a fully automated conversational agent (woebot): a randomized controlled trial towards interpersonal assistants: next-generation conversational agents designing for health chatbots approaches for dialog management in conversational agents designing interactive systems to mediate communication between formal and informal caregivers in aged care guidelines for human-ai interaction what do we need to build explainable ai systems for the medical domain what makes a good conversation?: challenges in designing truly conversational agents discourse analysis designing emotionally sentient agents evaluating and informing the design of chatbots chatbots, humbots, and the quest for artificial general intelligence resilient chatbots: repair strategy preferences for conversational breakdowns a study on machine learning enabled iot devices for medical assistance kbot: knowledge-enabled personalized chatbot for asthma self-management key: cord-330737-6khv4kbj authors: cohen, jennifer; van der meulen rodgers, yana title: contributing factors to personal protective equipment shortages during the covid-19 pandemic date: 2020-10-02 journal: prev med doi: 10.1016/j.ypmed.2020.106263 sha: doc_id: 330737 cord_uid: 6khv4kbj this study investigates the forces that contributed to severe shortages in personal protective equipment in the us during the covid-19 crisis. problems from a dysfunctional costing model in hospital operating systems were magnified by a very large demand shock triggered by acute need in healthcare and panicked marketplace behavior that depleted domestic ppe inventories. the lack of appropriate action on the part of the federal government to maintain and distribute domestic inventories, as well as severe disruptions to the ppe global supply chain, amplified the problem. analysis of trade data shows that the us is the world's largest importer of face masks, eye protection, and medical gloves, making it highly vulnerable to disruptions in exports of medical supplies. we conclude that market prices are not appropriate mechanisms for rationing inputs to health because health is a public good. removing the profit motive for purchasing ppe in hospital costing models and pursuing strategic industrial policy to reduce the us dependence on imported ppe will both help to better protect healthcare workers with adequate supplies of ppe. since early 2020 the us has experienced a severe shortage of personal protective equipment (ppe) needed by healthcare workers fighting the covid-19 pandemic (emanuel et al., 2020; livingston, desai, & berkwits, 2020) . in protests covered by the news media, healthcare workers compared themselves to firefighters putting out fires without water and soldiers going into combat with cardboard body armor. medical professionals have called for federal government action to mobilize and distribute adequate supplies of protective equipment, especially gloves, medical masks, goggles or face shields, gowns, and n95 respirators. n95 respirators, which have demonstrated efficacy in reducing respiratory infections among healthcare workers, have been in particularly short supply (macintyre et al., 2014) . without proper ppe, healthcare workers are more likely to become ill. a decline in the supply of healthcare due to worker illness combines with intensified demand for care, causing healthcare infrastructure to become unstable, thus reducing the quality and quantity of care. sick healthcare workers also contribute to viral transmission. hence ill practitioners increase the demand for care while simultaneously reducing health system capacity. this endogeneity makes a ppe shortage a systemwide public health problem, rather than solely a worker's rights or occupational health issue. ppe for healthcare workers is a key component of infection prevention and control; ensuring that healthcare workers are protected means more effective containment for all. we investigate the four main contributing factors behind the us shortage of ppe in 2020 and their interaction. first, a dysfunctional budgeting model in hospital operating systems incentivizes hospitals to minimize costs rather than maintain adequate inventories of ppe. second, a major demand shock triggered by healthcare system needs as well as panicked j o u r n a l p r e -p r o o f journal pre-proof marketplace behavior depleted ppe inventories. third, the federal government failed to maintain and distribute domestic inventories. finally, major disruptions to the ppe global supply chain caused a sharp reduction in ppe exported to the us, which was already highly dependent on globally-sourced ppe. market and government failures thus led ppe procurement by hospitals, healthcare providers, businesses, individuals, and governments to become competitive and costly in terms of time and money. the remainder of this article provides detailed support for the argument that the enormous ppe shortages arose from the compounding effects of these four factors. we conclude that because health is a public good, markets are not a suitable mechanism for rationing the resources necessary for health, and transformative changes are necessary to better protect healthcare practitioners. the 2020 shortage of ppe was an eventuality that nonetheless came as a surprise. the us experienced heightened demand for ppe in the mid-to late-1980s following the identification of the human immunodeficiency virus and the release of centers for disease control (cdc) guidelines for protecting health personnel (segal, 2016 (hersi et al., 2015) . although various stakeholders (governments, multilateral agencies, health organizations, universities) warned of the possibility of a major infectious disease outbreak, particularly pandemic influenza, most governments were underprepared. the world economic forum's annual global risks report even showed a decline in the likelihood and impact of a spread of infectious diseases as a predicted risk factor between 2015 and 2020 (wef, 2015 (wef, , 2020 . the problems created by lack of preparation were exacerbated by the high transmissibility of covid-19 and the severity of symptoms. contributing to the inadequate stockpiles of ppe were the trump administration's policies -which included public health budget cuts, "streamlining" the pandemic response team, and a trade war with the country's major supplier of ppeweakening the cdc's capacity to prepare for a crisis of this magnitude (devi, 2020) . the ppe shortage is reflected in survey data on ppe usage and in data on covid-19 morbidity and mortality. as of may 2020, 87% of nurses reported having to reuse a single-use disposable mask or n95 respirator, and 27% of nurses reported they had been exposed to confirmed covid-19 patients without wearing appropriate ppe (nnu, 2020). as of july 28, 2020, at least 1,842 nurses, doctors, physicians assistants, medical technicians, and other healthcare workers globally, and 342 in the us, have died due to the virus, and many more have become sick (medscape, 2020) . the cdc aggregate national data of 114,529 cases among healthcare personnel and 574 deaths (cdc, 2020b). healthcare workers have died from covidhealthcare worker deaths by state recorded in medscape (2020) are correlated with cdc (2020b) covid-19 cases by state (pearson's r of 0.552, p<0.00) and even more strongly correlated with cdc-confirmed covid deaths in the general population (pearson's r of 0.953, p<0.00). these correlation coefficients are indicative of healthcare worker exposure to the virus, and of the critical role of ppe and healthcare systems for population health. in other words, population health is a function of the healthcare system and wellbeing of healthcare workers, and the wellbeing of healthcare workers is a function of the healthcare system and ppe. we now turn to our analysis of ppe shortages, which identifies on four contributing factors: the way that hospitals budget for ppe, domestic demand shocks, federal government failures, and disruptions to the global supply chain (figure 2 ). these four factors arose from a number of processes and worked concurrently to generate severe shortages. the first factor the budgeting model used by hospitals is a structural weakness in the healthcare system. the occupational safety and health administration (osha) requires employers to provide healthcare workers with ppe free of charge (barniv, danvers, & healy, 2000; osha, 2007) . from the perspective of employers, ppe is an expenditurea cost. ppe is unique compared to all of the other items used to treat patients (such as catheters, bed pans, and medications) which operate on a cost-passing model, meaning they are billed to the patient/insurer. an ideal model for budgeting ppe would align the interests of employers, healthcare workers, and patients and facilitate effective, efficient care that is safe for all. instead, the existing structure puts employers who prioritize minimizing costs and healthcare workers who prioritize protecting their safety and the health of their patients in opposition, leaving governmental bodies to regulate these competing priorities (moses et al., 2013) . employers, be they privately-owned enterprises, private healthcare clinics, or public hospitals, seek to minimize costs. in economic theory, cost-minimization is compelled through market competition with other suppliers. in practice, cost-minimization is a strategy for maintaining profitability or revenue. therefore, hospital managers adopt cost-effective behaviors by reducing expenditures in the short term to lower costs (mclellan, 2017) . despite some hospitals' tax-exempt status, hospitals function like other businesses: they pursue efficiency and cost minimization (bai & anderson, 2016; rosenbaum, kindig, bao, byrnes, & o'laughlin, 2015) . the pursuit of efficiency means hospitals tend to rely on just-in-time production so that they do not need to maintain ppe inventories. the osha requirement effectively acts as an unfunded mandate, imposing responsibility for the provision of ppe, and the costs of provision, on employers. when it is difficult to pass along the costs of unfunded mandates to workers (in the form of lower wages) or customers (in the form of higher prices), employers resist such cost-raising legal requirements. the tension between healthcare workers and employers over ppe is evident in the way nurses' unions push federal and state agencies to establish protective standards. it is demonstrated by the testimony of the co-president of national nurses united to the committee on oversight and government reform in the us house of representatives in october 2014. she advocated for mandated standards for ppe during the ebola virus while employers were pushing for voluntary guidelines: [o]ur long experience with us hospitals is that they will not act on their own to secure the highest standards of protection without a specific directive from our federal authorities in the form of an act of congress or an executive order from the white house…the lack of mandates in favor of shifting guidelines from multiple agencies, and reliance on voluntary compliance, has left nurses and other caregivers uncertain, severely unprepared and vulnerable to infection (govinfo, 2014). employer resistance is short-sighted but unsurprising in the existing costing structure. the costing structure for other items, like catheters, allows employers to pass costs on to patients and insurers. the implication is that if employers (hospitals) cannot pass along the cost of the osha mandate to insurance companies, then employers do not have an economic incentive to encourage employees to use ppe, replace it frequently, or keep much of it in stock, at least until any gains from cost-minimization are lost due to illness among employees. the budgeting model is especially problematic when demand increases sharply, such as during the ebola virus in 2014 and the h1n1 influenza pandemic in 2009. as the site where new pathogens may be introduced unexpectedly, hospitals are uniquely challenged compared to other employers to provide protection (yarbrough et al., 2016) . but even during predictable fluctuations in demand, the existing model does not ensure that adequate quantities of ppe are available. however, previous studies have framed these problems as consequences of noncompliance among healthcare workers rather than noncompliance among employers (ganczak & szych, 2007; gershon et al., 2000; nichol et al., 2013; sax et al., 2005) . hospitals might be incentivized to avoid shortages by passing ppe costs on to patients and insurers, like other items used in care, but that approach is not the norm. this alternative cost-passing model also leaves much to be desired. where the current model induces tension between workers and employers, a cost-passing model would effectively situate practitioners against patients (cerminara, 2001) . if patients pay the costs of ppe, they might prefer that practitioners are less safe to defray costs. such a model is detrimental to both healthcare workers and patients. introducing tension to a relationship built on care and trust is precisely why the employer, not the patient, should be required to provide ppe to healthcare workers at no cost to j o u r n a l p r e -p r o o f journal pre-proof the worker. practitioners and patients should be allowed to share the common goal of improving patients' well-being. some labor economists argue that employers could (or do) pay compensating wage differentials to compensate healthcare workers for working in unsafe conditions (hall & jones, 2007; rosen, 1986; viscusi, 1993) . they believe that workers subject to hazardous conditions command a higher wage from employers compared to workers in less dangerous employment. higher wages for healthcare workers would then be embedded in the costs of care, which include pay for practitioners, that are passed along to insurance companies. however, this counterargument does not apply to healthcare practitioners because its necessary conditions are not met. workers would need perfect foresight that a crisis would require more protective equipment, knowledge of their employers' stockpile of ppe, perfect information about the hazards of the disease, and how much higher a wage they would need as compensation for these risks. this information is not available for workers who may be exposed to entirely novel pathogens that have unknowable impacts. neither the existing budgeting model nor the cost-passing model align the interests of the employer, healthcare worker, and patient. yet these three agents have a shared interest in practitioners' use of ppe. ppe, like catheters, are inputs to health. but unlike catheters, the primary beneficiary of ppe use is less easily identifiable than that of other inputs. while healthcare practitioners may appear to be the primary beneficiaries of ppe, the benefits are more diffuse. patients benefit from having healthy nurses who are not spreading infections, nurses benefit from their own health, and hospitals benefit from have a healthy workforce. nurses' health is an input to patient health, to the functioning of the hospital, and to the healthcare system. in other words, every beneficiary depends on nurses' health, which depends on ppe. still, employers' short-term profit motive dominates the interests of healthcare workers and patients, which suggests that alternative models that are not motivated by profit-seeking should be explored. the second contributing factor to the us shortage of ppe during the covid-19 outbreak was the rapid increase in demand by the healthcare system and the general public. in a national survey of hospital professionals in late march 2020 close to one-third of hospitals had almost no more face masks and 13% had run out of plastic face shields, with hospitals using a number of strategies to try to meet their demand including purchasing in the market and soliciting donations (kamerow, 2020) . american consumers also bought large supplies of ppe as the sheer scale of the crisis and the severity of the disease prompted a surge in panic buying, hoarding, and resales of masks and gloves. as an indicator of scale, in march 2020 amazon cancelled more than half a million offers to sell masks at inflated prices and closed 4,000 accounts for violating fair pricing policies (cabral & xu, 2020) . panicked buying contributed to a sudden and sharp reduction in american ppe inventories, which were already inadequate to meet demand from the healthcare system. there were two different kinds of non-healthcare buyers of ppe. a subset sought profits and bought and hoarded ppe items such as n95 respirators with the intent of reselling them at inflated prices (cohen, forthcoming) . it is likely that the majority, however, were worried consumers. while it may be tempting to blame consumers for seemingly irrational consumption, their decisions are more complex. panic buyers are consumers in the moment of buying ppe, but they are workers as well; people buy ppe because they are afraid of losing the ability to work j o u r n a l p r e -p r o o f and support themselves and their families. put simply, the dependence of workers on wages to pay for basic necessities contributes to panic when their incomes are threatened. this is rational behavior in the short term given existing conditions and economic structures. still, ppe belongs in the hands of those whose health has many beneficiaries: practitioners. eventually both the profiteer and the average, panicked worker/consumer will require healthcare, and contributing to the decimation of the healthcare work force is in no one's interest. underlying consumption behavior was intense fear of not only the disease but also fear of shortages. this panic reverberated throughout the supply chain as manufacturers tried to increase their production capacity to meet the demand for ppe (mason & friese, 2020) . one can conceptualize this mismatch between ppe demand and supply in an ability-topay framework. in much of economic theory, markets match supply and demand to determine the price of a good or service, and the price operates as a rationing mechanism. market actors choose to buy or sell at that given price. but there are problems with this framework. on the demand side, some people cannot "choose" to buy a product because they cannot afford it; they lack the ability to pay, so the decision is made for them. an example is a potential trip to the doctor for the uninsured. for many americans, whether to go to the doctor, or whether to have insurance, is not a choice; the choice is made for them because they are unable to pay. on the supply side, the ability-to-pay framework remains, except the product in question is an input. in healthcare, the practitioner is the proximate supplier of care and inputs to health are intermediate goods. the supplier's -or their employer'sability (and willingness) to pay for inputs to care, including ppe, determines the quality and quantity of care the practitioner is able to supply. when healthcare workers do not have ppe (e.g. because others bought it and resold it at extortionary prices), they are unable to provide the care patients need. but reselling behavior is j o u r n a l p r e -p r o o f also economically rational, if unethical, at least in the short term. indeed, ability-to-pay works well for the hoarder/reseller, who both contributes to and profits from the shortage. it is in the pursuit of profitsof monetary gainthat the mismatch between ppe demand and supply resides. on the demand side there is a person in need of care who is constrained by their inability to pay, while on the supply side there is a practitioner who is constrained by their inability to access the resources required to provide high quality care safely. the ability-to-pay framework is incompatible with the optimal allocation of resources when the ultimate aim is something other than monetary gain. hence market prices are not a good mechanism for rationing vital inputs to health such as ppe, and the profit motive is ineffective in resolving this mismatch between demand and supply. given the large-scale failure of the market to ensure sufficient supplies of ppe for practitioners, the government could have taken a number of corrective actions: it could have coordinated domestic production and distribution, deployed supplies from the strategic national stockpile, or procured ppe directly from international suppliers (hhs, 2020; maloney, 2020). the us government has anticipated ppe shortages since at least 2006 when the national institute for occupational safety and health commissioned a report examining the lack of preparedness of the healthcare system for supplying workers with adequate ppe in the event of pandemic influenza (liverman & goldfrank, 2007) . in a scenario in which 30% of the us population becomes ill in pandemic influenza, the estimated need for n95 respirators is 3.5 billion (carias et al., 2015) . however, the actual supply in the us stockpile was far smaller at 30 j o u r n a l p r e -p r o o f million, thus serving as a strong rationale to invoke the defense production act to manufacture n95 respirators and other ppe (azar, 2020; friese et al., 2020; kamerow, 2020) . further, the ppe in the national stockpile was not maintained on a timely basis to prevent product expiration, forcing the cdc to recommend use of expired n95s (cdc, 2020a). adding to the problems of cdc budget cuts before and during the pandemic and their failure to stockpile ppe was the unwillingness of the federal government to invoke the defense production act to require private companies to manufacture ppe, ventilators, and other critical items needed to treat patients (devi, 2020) . by july 2020, at which time the us already had more covid-19 cases than any other country in the world, there were still calls from top congressional leaders and healthcare professionals, including the speaker of the house of representatives and the president of the american medical association, for the trump administration to use the defense production act to boost domestic production of ppe (madara, 2020; pelosi, 2020; j. rosen, 2020) . researchers had also begun to publish studies on how to safely re-use ppe as it became clear that shortages would continue (rowan & laffey, 2020) . hence even five months into the crisis, the profit motive was still inadequate to attract new producers, which indicates that markets do not work to solve production and distribution problems in the case of inputs to health. not only did the government poorly maintain already-inadequate supplies and fail to raise production directly, it also failed to provide guidance requested by private sector medical equipment distributors and the health industry distributors association (hida), a trade group of member companies (maloney, 2020) . the private sector sought guidance about accessing government inventories, expediting ppe imports, and how to prioritize distribution, as indicated in this communication from hida's president: specifically, distributors need fema and the federal government to designate specific localities, jurisdictions or care settings as priorities for ppe and other medical supplies. the private sector is not in a position to make these judgments. only the federal government has the data and the authority to provide this strategic direction to the supply chain and the healthcare system (m. . moreover, it was not until early april 2020 that the trump administration issued an executive order for 3m, one of the largest american producers and exporters of n95 respirators, to stop exporting masks and to redirect them to the us market (whitehouse.gov, 2020) . looking up the supply chain, at least one distributor proposed bringing efforts to procure ppe internationally under a federal umbrella to the trump administration (maloney, 2020, p. 11 ). states-as-buyers confront the same market-incentivized structural issues that individual buyers face. a single federal purchaser would reduce state-level competition for buying ppe abroad, and mitigate the resulting inflated prices and price gouging by brokers acting as intermediaries between states-as-buyers and suppliers. the federal government chose not to take on this role. the profound government failures related to producing, procuring, and distributing ppe effectively, in ways not achievable through markets, are likely to have long-term impacts. the same distribution companies characterized, "the economics of supplying ppe in these circumstances" as "not sustainable" (maloney, 2020, p. 3) . they also expressed concern about the ongoing availability of raw materials required to manufacture ppe in the future. hida member companies expressed these concerns about supply chain issues in calls with federal agencies between january and march 2020, specifically with respect to long-term supply chain issues impacting the upcoming 2020-21 flu season (maloney, 2020, p. 5) . in mid-june, fema officials acknowledged that, "the supply chain is still not stable" (maloney, 2020, p. 9 ). a smoothly functioning supply chain has immediate impacts on the ability of governments and health personnel to contain an epidemic. the infectiousness and virulence of the disease affects the demand for ppe, just as the supply chain's functionality impacts the spread of the disease by improving practitioners' ability to treat their patients while remaining safe themselves (gooding, 2016) . the us domestic supply chain of ppe has been unable to sufficiently increase production to meet the enormous surge in demand. a large portion of the ppe in the us is produced in other countries. excessive reliance on off-shore producers for ppe proved problematic in earlier public health emergencies (especially the 2009 h1n1 influenza pandemic and the 2014 ebola virus epidemic), and this lesson appears to be repeating itself during the covid-19 pandemic (patel et al., 2017) . the incentive for hospitals and care providers to keep costs down has kept inventories low and driven sourcing to low-cost producers, especially in china. china's low production costs combined with high quality have made it the global leader in producing a vast range of manufactured goods, including protective face masks, gloves, and gowns. even with the emergence of other low-cost exporters, china dominates the global market for ppe exports. meanwhile, the us is the world's largest importer of ppe. yet although the us is extremely dependent on the global supply chain, us manufacturers of ppe are also major exporters given the profits available in world markets. the trade data in table 1 show the world's four top exporters of face masks, eye protection, and medical gloves. the data is drawn from the un comtrade database, using trade classifications from the who's world customs organization for covid-19 medical supplies j o u r n a l p r e -p r o o f (who, 2020) . in these data, the category "face masks" includes textile face masks with and without a replaceable filter or mechanical parts (surgical masks, disposable face-masks, and n95 respirators); "eye protection" includes protective spectacles and goggles as well as plastic face shields; and "medical gloves" includes gloves of different materials such as rubber, cloth, and plastic (who, 2020). we collected data for the 2015-2019 period. because patterns in 2015-2017 were very similar to those of 2018, the china is the world's largest exporter of medical face masks and eye protection, followed not far behind by the us. the fact that the us recently exported such large amounts of a commodity that in early 2020 was marked by extreme shortages is indicative of the lack of public health planning and political will. unlike the case of masks and eye protection, the us is not a top exporter of medical gloves. the three largest exporters of medical gloves are all in asia and are well endowed with natural rubber. table 1 also shows that the us is by far the largest importer of face masks, eye equipment, and medical gloves in the world market, followed by japan, germany, france, and the uk. overall, this analysis points to the high vulnerability of the us to disruptions in the global supply chain of face masks, eye protection, and medical gloves, and especially to disruptions in exports from china. the covid-19 outbreak in china in late 2019 led to a surge in demand within china for ppe, especially for disposable surgical masks as the government required anyone leaving their home to wear a mask. in response to demand, china's government not only restricted its ppe exports, it also purchased a substantial portion of the global supply (burki, 2020) . these shocks contributed to an enormous disruption to the global supply chain of ppe. as the virus spread to other countries, their demand for ppe also increased and resulted in additional pressure on dwindling supplies. in response, other global producers of ppe, including india, taiwan, germany, and france, also restricted exports. by march 2020, numerous governments around the world had placed export restrictions on ppe, which in turn contributed to higher costs. the price of surgical masks rose by a factor of six, n95 respirators by three, and surgical gowns by two (burki, 2020 overall then, with respect to imports, the us is the biggest importer and so is highly dependent on the global supply chain, and with respect to exports, the us failed to prioritize the country's public health needs. after the covid-19 outbreak, the us was late to restrict ppe exports as other countries did, and the government failed to take the opportunity to order millions of masks in the years leading up to covid-19 crisis, including the two-month period between when the virus was recognized in china and when local transmission was detected in the us. impacts. hence the seemingly gender-neutral costing model described in our analysis does not have gender-neutral outcomes. by implication, a meaningful change in the way healthcare is funded that incentivizes hospitals to invest in adequate inventories of ppe will disproportionately benefit women workers. the gender differential is even more striking in the case of home-health aides. more research is needed on the extent to which men and women are impacted differently by ppe shortages. another important question is the extent to which gender issuessuch as women's relative lack of bargaining power in hospital administrationcontributed to shortages to begin with. our analysis points to the need for transformative changes and corrective actions to better protect healthcare practitioners. we must consider a full range of tools that not only create incentives for hospitals to protect their care providers with ppe, but also generate effective institutional capacity to ensure that health providers can mobilize quickly to handle pandemics. we have several recommendations: (1) prepare hospitals to better protect practitioners by removing the profit motive from consideration in the purchasing and maintenance of ppe inventories; (2) strengthen the capacity of local, state, and federal government to maintain and distribute stockpiles; (3) improve enforcement of osha's current regulations around ppe, including requirements to source the proper size for each employee; (4) develop new regulations to reduce practitioner stress and fatigue (cohen & venter, 2020; fairfax, 2020) ; (5) improve the federal government's ability to coordinate supply and distribution across hospitals and local and state governments (patel et al., 2017) ; (6) consider strategic industrial policy to increase us production of medical supplies and to reduce the dependence on the global supply chain for ppe; (7) consider industrial policy to incentivize ppe production using existing technology while encouraging development, testing, and production of higher-quality, reusable ppe. these changes will address the costing-model issue, the demand problem, the federal government failures, and supply chain vulnerability, but they will not be politically palatable. creating the institutional capacity for building and maintaining a viable stockpile of ppe will j o u r n a l p r e -p r o o f contribute to all of these policy options. such shifts will help set the stage for what global health should look like moving forward. covid-19 was not the first pandemic nor will it be the last, especially given the likely impacts of climate change. congressional testimony: health and human services fiscal year 2021 budget request. c-span a more detailed understanding of factors associated with hospital profitability the impact of medicare capital prospective payment regulation on hospital capital expenditures global shortage of personal protective equipment. the lancet infectious diseases seller reputation and price gouging: evidence from the covid-19 pandemic potential demand for respirators and surgical masks during a hypothetical influenza pandemic in the united states considerations for release of stockpiled n95s beyond the manufacturer-designated shelf life contextualizing adr in managed care: a proposal aimed at easing tensions and resolving conflict covid-19 capitalism: the profit motive versus public health the integration of occupational-and household-based chronic stress among south african women employed as public hospital nurses invisible women: data bias in a world designed for men u.s.-china tariff actions by the numbers us public health budget cuts in the face of covid-19 fair allocation of scarce medical resources in the time of covid-19 the occupational safety and health administration's impact on employers: what worked and where to go from here respiratory protection considerations for healthcare workers during the covid-19 pandemic surgical nurses and compliance with personal protective equipment hospital safety climate and its relationship with safe work practices and workplace exposure incidents a mixed methods approach to modeling personal protective equipment supply chains for infectious disease outbreak response the value of life and the rise in health spending* effectiveness of personal protective equipment for healthcare workers caring for patients with filovirus disease: a rapid review strategic national stockpile. public health emergency covid-19: the crisis of personal protective equipment in the us preparing for an influenza pandemic: personal protective equipment for healthcare workers sourcing personal protective equipment during the covid-19 pandemic efficacy of face masks and respirators in preventing upper respiratory tract bacterial colonization and co-infection in hospital healthcare workers letter from american medical association to vice president michael pence memorandum: information provided by medical distribution companies on challenges with white house supply chain task force and project airbridge protecting health care workers against covid-19-and being prepared for future pandemics work, health, and worker well-being: roles and opportunities for employers in memoriam: healthcare workers who have died of covid-19 the anatomy of health care in the united states behind the mask: determinants of nurse's adherence to facial protective equipment new survey of nurses provides frontline proof of widespread employer, government disregard for nurse and patient safety, mainly through lack of optimal ppe employer payment for personal protective equipment; final rule personal protective equipment supply chain: lessons learned from recent public health emergency responses transcript of pelosi interview on cnbc's mad money with jim cramer/interviewer rosen, homeland security committee colleagues demand answers from administration on strategic national stockpile letter from health industry distributors association the theory of equalizing differences. handbook of labor economics the value of the nonprofit hospital tax exemption was $24.6 billion in challenges and solutions for addressing critical shortage of supply chain for personal and protective equipment (ppe) arising from coronavirus disease (covid19) pandemic -case study from the republic of ireland knowledge of standard and isolation precautions in a large teaching hospital the role of personal protective equipment in infection prevention history the value of risks to life and health global risks report global risks report 2020 memorandum on order under the defense production act regarding 3m company respirator use in a hospital setting: establishing surveillance metrics acknowledgements: the authors thank jacquelyn baugher, rn, bsn, ocn, for providing insight that aided our understanding of occupational relations internal to hospitals. key: cord-299804-2q8r5w2o authors: mitchell, a.; spencer, m.; edmiston, c. title: role of healthcare apparel and other healthcare textiles in the transmission of pathogens: a review of the literature date: 2015-08-31 journal: journal of hospital infection doi: 10.1016/j.jhin.2015.02.017 sha: doc_id: 299804 cord_uid: 2q8r5w2o summary healthcare workers (hcws) wear uniforms, such as scrubs and lab coats, for several reasons: (1) to identify themselves as hospital personnel to their patients and employers; (2) to display professionalism; and (3) to provide barrier protection for street clothes from unexpected exposures during the work shift. a growing body of evidence suggests that hcws' apparel is often contaminated with micro-organisms or pathogens that can cause infections or illnesses. while the majority of scrubs and lab coats are still made of the same traditional textiles used to make street clothes, new evidence suggests that current innovative textiles function as an engineering control, minimizing the acquisition, retention and transmission of infectious pathogens by reducing the levels of bioburden and microbial sustainability. this paper summarizes recent literature on the role of apparel worn in healthcare settings in the acquisition and transmission of healthcare-associated pathogens. it proposes solutions or technological interventions that can reduce the risk of transmission of micro-organisms that are associated with the healthcare environment. healthcare apparel is the emerging frontier in epidemiologically important environmental surfaces. solving the problem of healthcare-associated infections and occupationally acquired infections involves an equation with many complex variables. one of the key components is healthcare workers (hcws), such as doctors, nurses, laboratory personnel and technical professionals, who are frequently exposed to blood and body fluids. 1, 2 these fluids can transmit bacteria that cause colonization or infection, including multidrug-resistant organisms (mdros) such as meticillin-resistant staphylococcus aureus (mrsa), acinetobacter spp. and enterobacteriaceae (e.g. escherichia coli, klebsiella pneumoniae). there is also a risk of transmission of viruses, including noroviruses, respiratory viruses and bloodborne viruses (human immunodeficiency virus, hepatitis b and c viruses), that can survive for hours or days on surfaces. 1,3e18 in addition to the risk to hcws acquiring micro-organisms through workplace exposures, hcws who are already colonized with these microorganisms represent a risk to patients; studies have reported that 2e15% of hcws are colonized or infected with mrsa. 8,9,15e18 another consideration is the changes that are occurring in the way that patient care is delivered. while acute care personnel, such as those in hospital operating rooms and emergency departments, anticipate splashes and splatters of blood and body fluids, and use personal protective equipment (ppe) accordingly, new medical technologies allow for performing invasive procedures outside of the acute care environment. it may be more difficult to avoid accidental exposures to blood and body fluids in such settings, ppe may be less accessible, and as hcws are likely to be working with little or no supervision, they may be less compliant with standard infection control precautions. thus, hcws who work in nontraditional settings, such as clinics, and ambulatory and community settings, may be at increased risk of occupational exposure to infectious micro-organisms. in addition, hcws often travel to and from healthcare facilities by public transportation wearing their work clothing, creating another route by which micro-organisms can be imported into, and exported from, the healthcare environment. 19, 20 not only are the modes of healthcare changing, but another threat comes from the impact of globalization of travel. over the years, the emergence of novel infections has revealed gaps in public health preparedness for infectious disease in most countries. for example, in the early 2000s, gaps were identified in the preparedness for severe acute respiratory syndrome (sars), and significant gaps were noted again last year in the responses to both ebola virus disease (evd) and middle east respiratory syndrome coronavirus (mers). in the usa, this was tragically exemplified by the two hcws who acquired evd from one patient who travelled from west africa to dallas, texas. 21 viruses such as ebola can be transmitted easily in body fluids to healthy populations. healthcare facilities may not be prepared to prevent these types of transmissions. a survey of more than 1000 members of the association for professionals in infection control and epidemiology (apic) found that only 6% felt that their hospitals were fully prepared for emerging threats like ebola, and 20% had yet to begin training their workers. 22 finally, while considerable effort is placed on cleaning and disinfection of non-porous or high-touch environmental surfaces, much less effort is placed on the procedures for cleaning and decontaminating porous, soft surfaces or healthcare textiles (e.g. privacy curtains, linen, upholstery, patient furniture or room furnishings). these textiles include uniforms, scrub suits and other apparel. the complex role that these textiles play in acquisition and retention of pathogens is further complicated by varied laundering conditions and requirements, including whether or not the employer allows employees to launder their work-related apparel at home. while the us centers for disease control and prevention (cdc) and other government agencies around the world provide guidance for laundering contaminated textiles, achieving optimal water temperature, drying time and dedicated process flow can be difficult to achieve in healthcare facilities, and nearly impossible in homes. contaminated textiles, specifically uniforms and apparel worn in healthcare settings, have been subject to recent study and debate. the role that active barrier textiles, including antimicrobial and fluid-repellent properties, could play in preventing occupationally acquired and healthcare-associated illnesses and infections among both patients and workers has been researched, and there is now some evidence to support their use as an effective strategy for preventing crosscontamination. this paper provides a summary review of current evidence of the risks around textiles in healthcare settings, and the potential benefits of novel fabrics to prevent transmission of infectious agents to and from hcws. experts believe that textiles (i.e. curtains, upholstery, apparel, etc.) play an important role in the acquisition and transmission of pathogens in healthcare. 23e29 hcws' apparel is a vehicle for cross-contamination and transmission of mdros. 30e48 contaminated soft surfaces make an important contribution to the epidemic and endemic transmission of clostridium difficile, vancomycin-resistant enterococci (vre), mrsa, acinetobacter baumannii, pseudomonas aeruginosa and norovirus. 49e61 ohl et al. reported that 92% of hospital privacy curtains are contaminated rapidly (within one week) with potentially pathogenic bacteria, such as mrsa and vre. 25 a review by otter et al. stated that micro-organisms shed by patients can contaminate hospital surfaces at concentrations sufficient for transmission. 51 these pathogens survive and persist for extended periods despite attempts to disinfect or remove them, and can be transferred to hcws' hands. according to otter et al., the perspective that contaminated surfaces contribute 'negligibly to nosocomial transmission is no longer valid given the new line of scientific evidence'. 51 unlike curtains and other environmental textiles, apparel worn in the healthcare environment moves quickly around the healthcare facility and is likely to represent a better source of substrates for bacterial growth. microbes tend to thrive in moisture and protein-rich soil or dirt that may be found on apparel. thus, apparel can readily acquire, retain and transmit epidemiologically significant pathogens such as mrsa. typically, hcws will wear the same clothing for one day or more, during which time their apparel will have direct or indirect contact with coworkers, patients and the general public. 36, 38, 62 at the end of a work shift, c. difficile and mrsa can be recovered from the surfaces of nurses' uniforms at counts exceeding 500 colony-forming units (cfu). 23 in one study, 23% and 18% of lab coats were contaminated with meticillinsensitive s. aureus (mssa) and mrsa, respectively. 34 weiner-well et al. reported that up to 60% of hospital staff uniforms were culture positive for mdros, based on samples taken from the sleeves, waists and pockets of the work apparel of over 100 physicians and nurses. 30 healthcare-associated pathogens were isolated from at least one site on 63% of the uniforms. krueger et al. examined the bacterial profiles of medical residents' worn and unworn scrubs, and found that even laundered and unworn scrubs harboured normal skin flora. 61 in an observational study across six intensive care units at a tertiary care hospital, morgan et al. reported that 21% of hcwepatient interactions resulted in contamination of the hcw's gloves or gowns, most often with multi-drug-resistant a. baumannii. 58 they concluded that environmental contamination was the best predictor of mdro transmission to hcws' attire. treakle et al. and others confirmed that lab coats are contaminated by their wearers (i.e. physicians, residents, nurses) in acute care settings in various departments. 31, 34, 39, 43, 45, 46, 62, 63 outside of hospital settings, gaspard et al. established that high levels of mrsa contaminate hcws' uniforms in long-term care facilities. 50 another study aimed to determine the association between the bacterial contamination of hcws' hands and lab coats and scrub suits. cultures were obtained from the hands, lab coats and scrubs of hcws in five intensive care units, and 86% of 103 hcws' hands were found to be contaminated: 13 (11%) with s. aureus, seven (6%) with acinetobacter spp., two (2%) with enterococci and 83 (70%) with skin flora. there was a greater likelihood of bacterial pathogens on the lab coats if the hands were also positive, but not on the scrubs. the presence of acinetobacter spp. on hcws' hands was associated with a greater likelihood of contamination of lab coats but not scrubs. 35 protecting hcws and other workers who must respond to infectious disease outbreaks and crises requires an effective occupational health programme. in its guidance on worker safety in hospitals, the us occupational safety and health administration (osha) stated that an infection prevention programme must include controls for both patient and hcw, and the best programmes incorporate the two as functions of each other. 64 the appropriate use of ppe, including the proper timing and donning of gloves and isolation gowns when interacting with colonized or infected patients, is viewed as an important risk reduction strategy. in addition, isolating patients in single rooms, or room cohorting, are viewed as sentinel practices for reducing the risk of cross-contamination and transmission of healthcare-associated pathogens. 43,63,65e69 proper hand hygiene, including handwashing with soap and running water, the use of alcohol-based hand rubs, and appropriately timed glove use, is a key factor in controlling the transmission of mrsa to patients and staff. workers' hands contribute greatly to the transmission of healthcare-associated pathogens. 70e83 disrupting the points of contact in this network of transmission is a critical strategy in preventing the transmission of mrsa and vre. neely and maley studied the survival of 22 gram-positive bacteria, including vre, mssa and mrsa, on common hospital materials. 24 they inoculated five types of hospital materials with 10 4 to 10 5 cfu of the different bacteria. the materials included smooth 100% cotton clothing, 100% cotton terry towels, 60% cotton/40% polyester blend scrub suits, 100% polyester privacy curtains and 100% polypropylene plastic aprons. all isolates were detectable for at least one day, and some survived for more than 90 days. 35 these results demonstrate the need for meticulous contact control procedures and careful disinfection to limit the spread of these bacteria. of course, even after performing proper hand hygiene and donning gloves, workers can contaminate their gloved hands by touching themselves or objects in the environment (including high-touch surfaces) prior to touching their patients. for example, an observational study of office workers found that they commonly touch their eyes, lips, nostrils etc. at a rate of 15.7 times per hour. 84 hcws may be more cognizant of the need to keep their gloved hands away from their body, but loveday et al. reported that gloved hcws touched an average of three objects, such as clinical equipment around the patient or urine bottles/bedpans, in the patient zone prior to performing a healthcare procedure. 85 in addition, while proper hand hygiene and use of ppe are considered to be the cornerstones of any effective infection control programme, compliance with hand hygiene protocols and requirements for using ppe remain problematic. 43, 63, 65, 66 ,68e73, 86 mitchell described occupational exposures to blood over a cohort of more than 60 hospitals, and noted that use of ppe can vary between 25% and 75% from incident reports from lower-risk hospital areas compared with higher-risk hospital areas. 87 also, while there are wellestablished guidelines to protect both hcws and patients from cross-contamination in the operating room and isolation precaution settings, there is little guidance specific to areas outside of these traditionally high-risk hospital departments. it is in other departments with less focus where there may be more environmental touch points and thus higher risk of transmission. 48, 59, 67, 68 as such, relying heavily on the use of ppe and high-touch environmental disinfection is not sufficient to prevent the spread of micro-organisms that cause infection and illness. when hcws are caring for laboratory-confirmed patients in isolation, they are likely to be more conscientious about handwashing and the use of ppe when they anticipate exposures. however, few facilities perform routine active screening for any mdros, which results in caring for unconfirmed patient cases and thus unanticipated (and possibly unprotected) exposures. given the trend towards outpatient and out-ofhospital treatment and procedures, hcws may not have the acute care workplace reliance on, and awareness of the potential for, exposure, contamination and possible transmission of pathogens. another consideration in infection control is hcws as a source for mdros. researchers estimate nasal carriage of mrsa in hcws as between 6e8% or higher. 4 however, others have reported endemic non-outbreak carriage rates as high as 15%. 3 a study of 135 surgeons and residents found that 1.5% were positive for mrsa and 35.7% were positive for mssa. 88 none of the 61 residents were positive for mrsa, but 59% were positive for mssa. of the 74 attending surgeons, 2.7% were positive for mrsa and 23.3% were positive for mssa. danzmann et al. reviewed 152 outbreaks, mainly from surgery, neonatology and gynaecology departments. 89 the most common infections were surgical site infections, hepatitis b virus and septicaemia. physicians were involved in 59 outbreaks (41.5%) and nurses were involved in 56 outbreaks (39.4%). causes of the outbreaks were mainly transmission via direct contact. hcws may have options to launder their work clothing, or some institutions may offer onsite industrial laundering for scrubs, lab coats and other apparel. generally, industrial laundry procedures are sufficient to return garments and textiles free of microbial contamination. however, as fijan et al. discovered, no procedure is foolproof, and even if the laundering process itself produces nearly sterile garments, postlaundering practices (e.g. sorting, folding and stacking) can recontaminate clean laundry unless housekeeping personnel maintain a high level of vigilance. 29,90e92 fijan et al. concluded that insufficient antimicrobial laundry procedures can result in spreading micro-organisms throughout even the clean areas of laundry facilities. they found that: (1) workers can recontaminate clean laundry unless they receive regular training and education on proper hygiene and work area cleaning and disinfecting procedures; and (2) regular cleaning and disinfecting of all laundry areas, especially the clean laundry area, is necessary to prevent the recontamination of laundered textiles during the post-laundry handling processes such as sorting, ironing, folding and packing. fijan et al. specifically investigated the potential for hospital textiles to transmit rotaviruses, and noted that rotavirus rna could be detected in hospital laundry rinse water after the washing process, even after using accepted laundering procedures, and on laundered textiles, environmental surfaces in the laundry area and the hands of laundry workers. while industrial laundry practices and procedures may be problematic with regard to ensuring that 'clean' clothes are truly free of microbial contamination, laundering at home may not be a safe solution. wright et al. recently described the investigation of a cluster of three instances of gordonia bronchialis sternal infection. 60 after ruling out environmental contamination, the researchers identified a nurse anaesthetist as the source of the outbreak. four separate strains of g. bronchialis were isolated from her scrubs, axilla, hands and handbag. the investigators also obtained cultures from her nurse roommate, and grew g. bronchialis from that nurse's axilla, hands and scrubs. in an effort to decontaminate her home, the nurse anaesthetist disposed of the washing machine that she had been using to launder her work uniforms. after disposal of the machine, the nurse anaesthetist's and her roommate's scrubs, hands, nares and scalps all tested negative for g. bronchialis and the infection outbreak ceased. uncertainties about the effectiveness of home laundering are further illustrated in another study which reported that 39% of nurses' uniforms laundered at home were contaminated with mdros at the beginning of the work shift. 30, 31, 36, 39 the laundry conundrum is further complicated because, even if the laundering procedures, whether at home or at work, produce clean textiles, bacterial recontamination of these surfaces will occur within hours of donning newly laundered uniforms. the previously mentioned home-laundered nurses' uniforms showed an increase in contamination from 39% at the beginning of the work shift to 54% by the end of the day. a separate analysis indicated that 100% of nurses' gowns were contaminated within the first day of use, and 33% of those were contaminated with s. aureus. 36 pockets and cuffs may be the areas of highest microbial contamination. 43 burden et al. found that uniforms that were almost sterile prior to donning accumulated nearly 50% of their 8-h measured cfu count after only 3-h of wear. 31 those researchers also found no significant differences in cfu counts from previously-worn lab coats vs newly-laundered uniforms, sleeve cuffs of either type of garment, or the pockets of lab coats vs uniforms. results of the cultures showed that 16% of the lab coats and 20% of the short-sleeved uniforms were positive for mrsa. burden et al. concluded that reducing bacterial contamination of hcws' clothing made of conventional fabrics would require changing work clothes every few hours. 22 the usa falls behind many other countries, especially those in europe, because, typically, only scrub suits worn in the operating room and isolation gowns are laundered by the healthcare facility with commercial or industrial laundering capabilities. the us cdc recommends that contaminated laundry should be washed at water temperatures of at least 160 f (70 c), using 50e150 ppm of chlorine bleach to remove significant quantities of micro-organisms from grossly contaminated linen. 93 this may be possible in healthcare laundry services; however, most scrub suits, lab coats and scrub jackets are washed at home, but typical temperatures of domestic washing machines do not exceed 110 f (45 c) due to child safety laws to prevent scalding and burns. most scrub manufacturers recommend against the use of bleach to preserve colour dye on the fabric, which is counter-intuitive to the infection prevention and infectious disease community. high drying temperatures, as well as physical agitation in both washing and drying cycles, may reduce pathogens to a sufficient threshold to reduce infectivity; however, this becomes problematic as many choose to either hand wash or hang dry items for various reasons. providing every hospital worker with the equivalent of nautical storm gear is impractical. however, technical or engineered textiles, including those with fluid repellency and embedded antimicrobials, have been on the market and readily available as separate technology options for years. unfortunately, there has been limited adoption of these types of technologies by healthcare institutions. perhaps an underlying reason for this is the failure of healthcare professionals to recognize the benefits of this innovative technology as a significant risk-reduction strategy. another reason may be the increased cost associated with these enhanced textiles. textile-based fluid or active barrier antimicrobial technology may be an effective strategy for preventing crosscontamination by reducing the burden of infectious microorganisms on the surface of healthcare apparel. bearman et al. identified a 6-log reduction in mrsa on scrub suits treated with a proprietary technology that includes a breathable, fluid barrier and non-leaching antimicrobial activity compared with scrubs that were not treated. 32 schweizer et al. reported that the median time to first contamination of privacy curtains was seven times longer for curtains incorporating a complex element compound with antimicrobial properties than for standard curtains. 94 they concluded that using privacy curtains with antimicrobial properties could increase the time intervals between necessary laundering, as well as possibly decrease the transmission of pathogens. studies have shown that textile-based antimicrobials alone may not be enough; fluid repellency is an important consideration in minimizing infectious dose for textile-based technologies. 95e98 not having hydrophobic repellency means that the organic material from blood and body fluids may actually interfere with the impregnated antimicrobial agent's ability to inhibit or kill bacterial contamination. several studies have assessed the effectiveness of textiles and apparel that use antimicrobials alone (i.e. silver, chitosan). 94e97 these studies indicate that an antimicrobial alone may not be sufficient to reduce the growth (and thus the retention and transmission) of micro-organisms. mitchell confirmed this and pointed out that several recent studies have found that textiles embedded with antimicrobials alone may not reduce overall contamination. 97 a consideration, however, is the role that antimicrobial textiles may play for use in environmental surfaces such as privacy curtains, upholstery or bedding compared with apparel or uniforms. the difference in effectiveness between application in these types of healthcare textiles warrants further study. other innovative textiles have been shown to inhibit growth and/or contamination. technical or engineered fabrics have reduced mrsa surface levels to near 0% in splatter, spray and contact challenge tests within 5 min. 99 in addition, bearman et al. documented four-to seven-log reductions for mrsa on technical or engineered fabrics with fluid repellency and antimicrobial properties compared with traditional control scrubs, both at the beginning and end of the nurse work shift. 32 they concluded that the use of an antimicrobial hydrophobic barrier is highly effective in reducing the microbial bioburden on the surface of hcws' scrubs. an important element of bearman et al.'s study is that it did not find a significant reduction in microbes other than mrsa. however, they discussed the fact that the baseline numbers of gram-negative bacteria in the hospital may have been too low to allow differences to be identified. when designing a study like this, it is important to identify epidemiologically significant microbes for the setting in which the study is being performed in order to determine if there is a significant difference when comparing two textile types. as a reminder, the us food and drug administration (fda) only requires in-vitro testing for manufacturers to make claims about antimicrobial capabilities when they submit for premarket notification. 100 as the fda does not require clinical testing, many antimicrobial products currently used in thousands of healthcare facilities may be sold without accompanying data validated in clinical or hospital settings. before purchasing any innovative antimicrobial or active barrier attire, healthcare facilities should determine whether the selected engineering controls have data derived from clinically relevant settings (e.g. crossover and/or randomized study designs in healthcare settings). facilities also need to consider the antimicrobial agent used and the mechanism of action, including whether it is leaching (ionic association) or a safer non-leaching alternative (covalently bonded). the literature illustrates that healthcare textiles, including uniforms or apparel, are a vector for transmission of microorganisms that cause infections and illnesses in hcws, patients and the community. while there is a growing platform of published studies on the topic, the impact is underestimated because of a lack of point source investigations of textiles during outbreaks and cases of infection or illness. many published papers either begin or end with a statement about the lack of published data in the literature on technical textiles or innovations in apparel. therefore, healthcare facilities, hospitals, outpatient clinics and academic institutions should use and study newly available controls, and report findings and outcomes in credible published outlets. ppe has a clear place in protecting hcws when there are anticipated exposures to blood and body fluids and contact transmissible pathogens. however, exploring innovations in apparel worn daily and textiles used daily may also prevent ongoing, endemic transmission to patients. the science indicates that antimicrobial embedded textiles alone are not enough. manufacturers can engineer or technically design textiles that reduce the acquisition, retention and transmission of infectious micro-organisms found in blood, body fluids and the environment that can also combat higher levels of soil or bioburden. to ensure best product design, safety, effectiveness and efficacy, this should involve collaborative partnerships between healthcare facilities, research institutes, academic settings, public agencies and manufacturers. we could all benefit by closing the gap between what uniforms or apparel are worn now and what is worn into the future. over time, apparel has advanced in industries where there is a risk of fire, with the introduction of textiles that are fire retardant or resistant. it is eminently feasible that in the years ahead, novel fabrics protecting against micro-organisms will become commonplace in healthcare industries. in closing, a statement by jagger, of the international healthcare worker safety center, nearly 10 years ago still holds true today, and can be broadened to include the risks associated with a broader array of pathogens: ' the basic measures for protecting hcws from the life-threatening risk of bloodborne pathogen infection should be viewed everywhere as essential and included in the national health priorities of all nations. the resources for this task are unlikely to be forthcoming unless we re-assess the value we place on hcws. they are not merely a service commodity; they are an invaluable asset to their countries and to the world community. without them there would be no health care. all of us benefit from protecting their lives and health.' 86 blood and body fluid exposures to skin and mucous membranes epidemiology and prevention of blood and body fluid exposures among emergency department personnel should hcws be screened routinely for methicillin-resistant staphylococcus aureus? a review of the evidence health-care workers: source, vector, or victim of mrsa? guideline for infection control in health care personnel spread of methicillin-resistant staphylococcus aureus in a hospital after exposure to a health care worker with chronic sinusitis a cloud adult: the staphylococcus aureusevirus interaction revisited outbreak of staphylococcal infection in two hospital nurseries traced to a single nasal carrier nosocomial transmission of a strain of staphylococcus aureus causing toxic shock syndrome outbreak of communityacquired methicillin-resistant staphylococcus aureus skin infections among health care workers in a cancer center update: human immunodeficiency virus infections in hcws exposed to blood of infected patients italian study group on occupational risk of hiv infection. the risk of occupational human immunodeficiency virus infection in hcws: italian multicenter study transmission of hepatitis c via blood splash into conjunctiva blood borne pathogen exposures among nursing staff: causes of exposures and responses. idsa poster #407 a prevalence study of methicillin resistant staphylococcus aureus colonization in emergency department health care workers staphylococcus aureus colonization among hcws at a tertiary care hospital prevalence of staphylococcus aureus nasal colonization in emergency department personnel prevalence of methicillin-resistant staphylococcus aureus nasal carriage in hcws bacterial contamination on touch surfaces in the public transport system and in public areas of a hospital in london public transport as a reservoir of methicillin-resistant staphylococci cdc and texas health department confirm first ebola case diagnosed in the us association for professionals in infection control and epidemiology. ebola readiness poll international scientific forum on home hygiene. the infection risks associated with clothing and household linens in home and everyday life settings, and the role of laundry survival of enterococci and staphylococci on hospital fabrics and plastic hospital privacy curtains are frequently and rapidly contaminated with potentially pathogenic bacteria bacterial transfer to and from fabrics dissemination of microorganisms by fabrics and leather rotaviral rna found in wastewaters from hospital laundry rotaviral rna found on various surfaces in a hospital laundry nursing and physician attire as possible source of nosocomial infections newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8-hour workday: a randomized control trial a crossover trial of antimicrobial scrubs to reduce methicillin-resistant staphylococcus aureus burden on healthcare worker apparel bacterial contamination of uniforms bacterial contamination of health careworkers' whitecoats associations between bacterial contamination of health care workers' hands and contamination of white coats and scrubs bacterial contamination of nurses' uniforms: a study detection of methicillinresistant staphylococcus aureus and vancomycin-resistant enterococci on the gowns and gloves of hcws contamination of nurses' uniforms with staphylococcus aureus transmission of nosocomial pathogens by white coats: an in-vitro model transfer of multidrug-resistant organisms to hcws' gloves and gowns after patient contact increases with environmental contamination the role of clothing and drapes in the operating room hospital gowns as a vehicle for bacterial dissemination in an intensive care unit compliance with routine use of gowns by hcws (hcws) and non-hcw visitors on entry into the rooms of patients under contact precautions contamination of protective clothing and nurses' uniforms in an isolation ward microbial flora on doctors' white coats bacterial flora on the white coats of medical students healthcare personnel attire in non-operating room settings frequent multidrugresistant acinetobacter baumannii contamination of gloves, gowns, and hands of hcws effect of clothing on dispersal of staphylococcus aureus by males and females methicillin resistant staphylococcus aureus contamination of hcws' uniforms in long-term care facilities the role played by contaminated surfaces in the transmission of nosocomial pathogens the survival and transfer of microbial contamination via cloths, hands and utensils virus transfer from personal protective equipment to healthcare employees' skin and clothing nosocomial transmission of salmonella gastroenteritis to laundry workers in a nursing home pillows, an unexpected source of acinetobacter carbapenemresistant acinetobacter and role of curtains in an outbreak in intensive care units zygomycosis outbreak associated with hospital linens transfer of multidrugresistant bacteria to healthcare workers' gloves and gowns after patient contact increases with environmental contamination importance of the environment in methicillinresistant staphylococcus aureus acquisition: the case for hospital cleaning gordonia bronchialis sternal wound infection in 3 patients following open heart surgery: intraoperative transmission from a healthcare worker the bacterial contamination of surgical scrubs the white coat of the future a review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions occupational safety and health administration committee on personal protective equipment for healthcare personnel to prevent the transmission of pandemic influenza and other viral respiratory infections. preventing transmission of pandemic influenza and other viral respiratory diseases: personal protective equipment for healthcare personnel. washington dc: institute of medicine agency for healthcare research and quality association for professionals in infection control and epidemiology. guide to the elimination of methicillin-resistant staphylococcus aureus (mrsa) transmission in hospital settings guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings use of personal protective equipment and operating room behaviors in four surgical subspecialties: personal protective equipment and behaviors in surgery improving adherence to hand hygiene practice: a multidisciplinary approach patient education model for increasing hand washing compliance effectiveness of a hospital-wide programme to improve compliance with hand hygiene epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs hand disinfection: a comparison of various agents in laboratory and ward studies a history of protective clothing communityacquired methicillin-resistant staphylococcus aureus in children with no identified predisposing risk increase in communityacquired methicillin-resistant staphylococcus aureus in children emergence of community-associated methicillin-resistant staphylococcus aureus usa 300 genotype as a major cause of health careassociated blood stream infections emergence of usa-300 mrsa in a tertiary medical centre: implications for epidemiological studies invasive methicillinresistant staphylococcus aureus infections in the united states high diversity of panton-valentine leukocidin-positive, methicillinsusceptible isolates of staphylococcus aureus and implications for the evolution of community-associated methicillin-resistant s. aureus national prevalence of methicillin-resistant staphylococcus aureus in inpatients at united states health care facilities occupational safety and health administration. 29 cfr part 1910 docket no.osha-2010-003 rin no. 1218-ac46 infectious diseases a study quantifying the hand-to-face contact rate and its potential application to predicting respiratory tract infection clinical glove use: healthcare workers' actions and perceptions caring for hcws: a global perspective occupational exposure to blood & body fluids in u.s. hospitals: implications of national policy. doctoral dissertation prevalence of staphylococcus aureus colonization in orthopaedic surgeons and their patients health care workers causing large nosocomial outbreaks: a systematic review hygiene monitoring systems for hospital textile laundering. london: hospital healthcare europe determining the hygiene of laundering industrial textiles in slovenia, norway and denmark implementing hygiene monitoring systems in hospital laundries in order to reduce microbial contamination of hospital textiles laundry: washing infected material novel hospital curtains with antimicrobial properties: a randomized, controlled trial a randomized crossover trial to decrease bacterial contamination on hospital scrubs working section for clinical antiseptic of the german society for hospital hygiene. pilot study on the microbial contamination of conventional vs. silver-impregnated uniforms worn by ambulance personnel during one week of emergency medical service making the case for textiles with a dual mechanism of action vtt003 textile reduction of mrsa burden: synergistic action of antimicrobial and hydrophobic chemistries. id week poster #947 fabric challenge assays: new standards for the evaluation of the performance of textiles treated with antimicrobial agents subpart e e premarket notification procedures none declared. none. key: cord-330814-7incf20e authors: parikh, priyanka a; shah, binoy v; phatak, ajay g; vadnerkar, amruta c; uttekar, shraddha; thacker, naveen; nimbalkar, somashekhar m title: covid-19 pandemic: knowledge and perceptions of the public and healthcare professionals date: 2020-05-15 journal: cureus doi: 10.7759/cureus.8144 sha: doc_id: 330814 cord_uid: 7incf20e background and objective the recent pandemic due to the novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2) has become a major concern for the people and governments across the world due to its impact on individuals as well as on public health. the infectiousness and the quick spread across the world make it an important event in everyone’s life, often evoking fear. our study aims at assessing the overall knowledge and perceptions, and identifying the trusted sources of information for both the general public and healthcare personnel. materials and methods this is a questionnaire-based survey taken by a total of 1,246 respondents, out of which 744 belonged to the healthcare personnel and 502 were laypersons/general public. there were two different questionnaires for both groups. the questions were framed using information from the world health organization (who), uptodate, indian council of medical research (icmr), center for disease control (cdc), national institute of health (nih), and new england journal of medicine (nejm) website resources. the questions assessed awareness, attitude, and possible practices towards ensuring safety for themselves as well as breaking the chain of transmission. a convenient sampling method was used for data collection. descriptive statistics [mean(sd), frequency(%)] were used to portray the characteristics of the participants as well as their awareness, sources of information, attitudes, and practices related to sars-cov-2. results the majority (94.3%) of the respondents were indians. about 80% of the healthcare professionals and 82% of the general public were worried about being infected. various websites such as icmr, who, cdc, etc., were a major source of information for the healthcare professional while the general public relied on television. almost 98% of healthcare professionals and 97% of the general public, respectively, identified ‘difficulty in breathing” as the main symptom. more than 90% of the respondents in both groups knew and practiced different precautionary measures. a minority of the respondents (28.9% of healthcare professionals and 26.5% of the general public) knew that there was no known cure yet. almost all respondents from both the groups agreed on seeking medical help if breathing difficulty is involved and self-quarantine if required. conclusion most healthcare professionals and the general public that we surveyed were well informed about sars-cov-2 and have been taking adequate measures in preventing the spread of the same. there is a high trust of the public in the government. there are common trusted sources of information and these need to be optimally utilized to spread accurate information. in december 2019, the 2019 novel coronavirus disease caused by novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2) emerged in china, followed by a rapid spread all over the world. on march 11, 2020 , the world health organization (who) raised its pandemic alert. as of april 11, 2020, covid-19 had caused over 95,269 deaths in 189 countries and overseas territories or communities [1]. in a connected world, fake news and rumor-mongering are common due to a surge in the use of the internet and social media. a confused comprehension in an emerging communicable disease of which even the experts have inadequate knowledge can lead to fear and chaos, even excessive panic, which has the probability to aggravate the disease epidemic [2] . during the sars epidemic from 2002 to 2004, there were misconceptions and hence excessive panic in the general public concerning sars. this led them to be resistant to comply with suggested preventive measures such as avoiding public transportation, going to a hospital when sick, etc. this contributed to the rapid spread of sars and resulted in a more serious epidemic situation [3] . a similar experience occurred during the ebola outbreak in 2009 in africa. these experiences underscore the vital role of engaging with the general public and healthcare professionals and the importance of monitoring their perception of disease epidemic control, which may affect the compliance of community to the precautionary strategies. understanding related factors affecting and influencing people to undertake precautionary behavior may also help decision-makers take appropriate measures to promote individual or community health. hence, it is crucial to understand people's risk perception and identify their trusted sources of information to effectively communicate and frame key messages in response to the emerging disease [4] . since it is the novel coronavirus, its epidemiological features are not well known and new studies and publications will take anywhere from a month to a year making it important to know and understand the level of knowledge and preparedness of the healthcare personnel in terms of the managing the virus affected patients. today healthcare professionals managing covid-19 across the world are in an unprecedented situation, having to make tough decisions and working under extreme pressures. decisions include equitable distribution of scant resources among the needy patients, balancing their own physical and mental healthcare needs along with those of the patients, aligning their desire and duty to patients with those to family and friends, and providing care for all unwell patients with constrained or inadequate resources. this may cause some to experience moral distress or mental health problems [5] . effective communication is a priority in who's covid-19 roadmap; accurate and salient messages will enhance trust and enable the public to make informed choices based on recommendations [6] . as the outbreak intensified, social media has taken on new and increased importance with the large-scale implementation of social distancing, quarantine measures, and lockdown of complete cities. social media platforms have become a way to enable homebound people to survive isolation and seek help, co-ordinate donations, entertain, and socialize with each other. social media platforms arguably support the conditions necessary for attitude change by exposing individuals to correct, accurate, health-promoting messages from healthcare professionals in order to investigate community responses to sars-cov-2, we conducted this online survey among the general public and healthcare professionals to identify awareness of sars-cov-2 (perceived burden and risk), trusted sources of information, awareness of preventative measures and support for governmental policies and trust in authority to handle sars-cov-2 outbreak and put forward policy recommendations in case of similar future conditions. we performed a cross-sectional survey of a convenient sample of respondents. the ethical approval for the study was taken from the institutional ethics committee -2, hm patel centre for medical care and education, karamsad via letter iec/ hmpcmce/ 2019 / ex. 07/ dated march 23, 2020. all participants were above 18 years of age conveniently selected from the public at large by reaching out to the general public and healthcare professionals by the authors. the participants were largely from india. the consent of the participants was taken at the beginning of the survey. two different self-administered questionnaires were used. the one for non-medical personnel (general public) is shown in table 1 , while the one for medical and paramedical personnel is shown in table 2 . descriptive statistics [mean (sd), frequency (%)] were used to portray the characteristics of the participants as well as their awareness, sources of information, attitudes, and practices related to sars-cov-2. due to large sample sizes in the healthcare professional group as well as the general public group, exploratory visual comparisons were presented without typical statistical tests of significance. a total of 744 health and allied professionals and 502 persons from people at large consented and completed the survey. a majority (94.3%) of the participants were indian residents with insignificant responses from outside india. it is presumed that the majority of the respondents are of indian residents but the possibility of a handful of them being non-indians cannot be ruled out because we did not collect demographic data. a comparison of awareness about sars-cov-2 between the general public and healthcare professionals is shown in table 3 . half of the general public respondents showed eagerness for the sars-cov-2 test without difficulty in breathing. a similar trend was observed among health professionals. almost all respondents from the general public (98%) and the healthcare professionals (100%) endorsed seeking medical help if the breathing difficulty was involved. slightly more healthcare professionals reported regular influenza vaccination as compared to the general public [175(23.5%) vs 76(15.1%)]. almost all the respondents agreed for selfisolation if needed. the majority of the respondents reported that they were washing the hands more frequently and knew the correct way of handwashing. we present here a study of the awareness of sars-cov-2 among healthcare professionals and the general public with a comparison of many features among them. it is heartening to note that the knowledge with respect to sars-cov-2 is relatively high among the respondents. there are, however, various limitations of the study and these are inherent due to the circumstances in which this survey was done. the study was begun on march 23, 2020, one day after janata curfew in india as requested by the prime minister and one day before the lockdown on march 24, 2020 [7] . the survey was filled during the days of the lockdown when the respondents had a lot of time on their hands and were probably active on social media as well as watching the television news. hence, it is quite relevant that many individuals have their information from these two sources, making it important to ensure that accurate information through verified channels and healthcare professionals are presented and broadcasted to the people. this also points towards the importance of the right people being active on social media so that they can communicate the scientifically validated information to the masses. the curfew and the lockdown ensured that the seriousness of the disease was impressed upon by the highest offices in the country, which is reflected in people taking good precautionary measures to protect themselves from the disease as well as break the chain of transmission. the cases in india have hence not risen to a very high number as rapidly as expected/projected, which also probably indicates that the message was well conveyed and well perceived. as this is a survey that was filled remotely, we need to be cautious in drawing strong conclusions. another limitation of the study is that the questionnaire was in the form of google forms and the language of conduct was english. this implies that the people who did not have access to the internet and were not literate were unable to be a part of this survey. but as the source of information for all the general public remains similar (television is ubiquitous in india), we can infer that they would have a similar response. we base this inference as the main sources of information of the public at large were newspapers, television, and whatsapp despite having access to websites and other online sources. in villages, often the literate readout regional newspapers and news received on mobiles to the rest of the family/friends to ensure dissemination of information. it is now known that the basic reproductive number (r0) of coronavirus is more in healthcare professionals as compared to the lay public and hence the relative indifference or "no worries" approach of healthcare professionals towards getting infected by sars-cov-2 is a concern. in the scenario where adequate personal protective equipment (ppe) may not be available to the healthcare facilities in india due to increased global demand, it is important that healthcare workers know their risk for being infected. in a recent study in mumbai, 79% of the healthcare professionals were aware of the various ppe required with only 54.5% of them being aware of isolation procedures needed for sars-cov-2 infected patients [8] . the numbers for paramedical staff were also lower. india imports raw materials for ppe production from china and south korea. due to the shortage of materials and low rate of supply, the availability has taken a massive hit resulting in an acute shortage in the market. it is highly likely that many healthcare professionals will not use appropriate ppe, will get infected, and further spread infections to patients [9] [10] [11] . the bhilwara cohort in rajasthan is an example of how a healthcare professional needs to protect against infection since he/she is likely to transmit it to others [12] . another example in mumbai is saifee hospital, which was shut down due to an infected healthcare professional who continued to work and passed on the infection to many during the asymptomatic phase. the sars-cov-2 disease presents a unique organism that can be spread for at least five days before developing symptoms and up to 37 days after presentation [13, 14] . given its high infectivity, it is a recipe for disaster if healthcare personnel gets it. we have not collected demographic information from the participants and hence it is possible that many of them work in situations where they may not anticipate getting infected. the previous few months have shown how surgeons, orthopedicians, dentists, etc., who typically do not deal with infectious diseases are getting infected by coronavirus [15, 16] . in this scenario, it is worrying that only 80% of healthcare professionals were worried while the public was slightly more worried (82%). the difference in the source of information for healthcare professionals and the general public is stark when we compare information garnered through social media. social media at 78.3% is the second-highest source for the general public, while the healthcare professionals give it a measly 1%. since social media is prone to fake news, it is heartening that healthcare professionals are not learning from it. however, the reliance of the general public on social media indicates that healthcare professionals, professional organizations, and government officers need to invest a significant proportion of their time and resources to be active on social media to disseminate correct news. the shots heard round the world rapid-response network is an example that needs to be followed [17] . in another example, we have dr. roberto burioni who has successfully given accurate data on social media. if more healthcare professionals were to enrich social media, it would be a useful platform for the public [18, 19] . while many government officials are active on twitter in india, the platform that is commonly used in india is whatsapp, telegram, instagram, and tiktok and these are dynamic and keep changing. whatsapp in the middle of this pandemic reduced the forwarding to just one person for a message that had been forwarded five times from the previous number of forwarding to five people (which was unlimited initially) [20] . it indicates the importance of this platform across the world for the spreading of messages. the healthcare professionals rated scientific journals at just about 40.9%. it may be due to the low availability of high-quality evidence or poor access that many healthcare professionals in india have to scientific journals, which are mostly published out of developed countries [21] . in a pandemic situation, this disparity in access can be catastrophic and hence most journals have provided open access to all coronavirus-related publications. healthcare professionals accessed websites such as who, medscape, mohfw, cdc, worldometers, covid19.com, icmr, uptodate, and pubmed, for reliable information, which is an indicator of their faith in health organizations across the world. interestingly though at a low 29.3%, much of the general public accessed similar websites such as who, mohfw, cdc, and icmr. at the time that the survey was administered, online webinars via zoom or other applications were just beginning in india to educate clinicians searching for answers. this is not reflected in our current study due to many of the responses being filled before the same or the respondents not being part of these audiences. the study authors have attended many of these meetings conducted by the indian academy of pediatrics, etc., and this information is made available via email or whatsapp messages. in a changing world, both healthcare professionals and the general public need to have reliable and accurate sources of information. the severity of illness was well identified by all who were surveyed as being difficulty in breathing. another heartening aspect was that precautionary measures were well known to both the groups of participants with appropriate hand washing techniques, avoidance of public gatherings, and covering of the mouth while coughing and sneezing as the top three precautionary measures. during the first week of march in india, all the telephone and cellular caller tunes were changed to advisories of how to prevent coronavirus disease and when to seek medical help, which included the above messages apart from appeals on television, etc [22] . there was less knowledge related to treatment and vaccine among both healthcare professionals and the general public, which was a disappointing finding for healthcare professionals as they were expected to be aware of this. the same could be said of the knowledge of the infectivity period and duration of being asymptomatic after infection. there was a good knowledge of the usage of masks among the general public and healthcare professionals except for the usage of medical masks for healthy people to protect themselves. the icmr and other bodies have issued guidelines on the usage of masks and this seems to have been disseminated widely [23] . there was also a low insistence on the need for testing those without respiratory difficulty. in a scenario where testing resources are limited, this is an appropriate response but since it is possible to have the infection without respiratory difficulty, especially early on, this disinterest in getting tested, especially in healthcare personnel is worrisome when there is enough evidence of spread from asymptomatic and mildly symptomatic persons. it is also likely that this response may be due to the fact during the time that this questionnaire was administered, the total cases rose from 400+ to about 800+ and the testing strategy of icmr was limited to those with contact or travel to sars-cov-2-affected areas [24] . since writing this manuscript, except for a single source event of a religious gathering in delhi, which caused the doubling of cases to increase from about seven days to 4.1 days, it is reasonable to conclude that adequate knowledge exists among the general public. we can only hope that this would be enough to ensure that lockdown to reduce transmission and flatten the curve will be successful [25] [26] [27] [28] . the covid-19 pandemic has affected the world in various ways. the deficiency of information, the need for accurate information, and the rapidity of its dissemination are important, as this pandemic requires the cooperation of entire populations. the rapid survey that we conducted had a good response and we show that healthcare professionals and the general public were quite well informed about the coronavirus. they are aware of the measures needed to be taken to reduce the spread of the disease. the knowledge present allows the authors to speculate that the lockdown in india would be effective. the public receives a large amount of information from social media such as whatsapp and the medical fraternity and government need to develop strategies to ensure that accurate information needs to spread in these fora. the public awareness is quite high and it is important that the knowledge of communication channels be known and be kept at the topmost priority throughout the pandemic. the following is part of the text of the approval letter indicating approval for the study. "your research proposal 'response of the public and health care providers to a pandemic of a new virus' was submitted for review and approval by committee members under exempt review. as it involves collection of data using anonymous online questionnaire with maintenance of privacy and confidentiality, it qualified for an exempt from full committee review. the matter was reviewed by committee members and decided to review it under 'exempt from full committee' review. after review and subsequent clarification by you, the project is approved by iec in its present form. as the online form has information and consent section, which needs to be read and accepted by the respondents before answering the study questions, committee waivers the need for any other consent for data collection.". animal subjects: all authors have confirmed that this study did not involve animal subjects or tissue. conflicts of interest: in compliance with the icmje uniform disclosure form, all authors declare the following: payment/services info: all authors have declared that no financial support was received from any organization for the submitted work. financial relationships: all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. other relationships: all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. the public's response to severe acute respiratory syndrome in toronto and the united states monitoring community responses to the sars epidemic in hong kong from day 10 to day 62 epidemiology of severe acute respiratory syndrome (sars): adults and children managing mental health challenges faced by healthcare workers during covid-19 pandemic who -communicating risk in public health emergencies india will be under complete lockdown for 21 days: narendra modi -economic times covid-19 awareness among healthcare students and professionals in mumbai metropolitan region: a questionnaire-based survey but no testing kits, from china -the economic times lack of ppe, poor infection control put medical staff at risk of covid-19 covid-19 outbreak: protective health gear in short supply -the economic times bhilwara's tale of negligence: infected docs, latest covid-19 case hint at possible community spread news18 guidance for discharge and ending isolation in the context of widespread community transmission of covid-19 clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study accessed coronavirus: aiims' doctor tests positive for covid-19 infection, says sources -deccan herald countering anti-vaccination trends and changing online opinion blasting for science covid fallout: whatsapp changes limit on forwarded messages, users can send only 1 chat at a time -economic times a scientometric analysis of indian research output in medicine during 1999-2008 on every call you make, you will hear a person coughing and that is annoying -indiatoday ministry of health and family welfare -guidelines on use of mask by public strategy of covid19 testing in india it would've been in 7.4 days -economic times how tablighi jamaat event became india's worst coronavirus vector flattening the much-talked covid-19 curve-how close are we in india? -research matters lockdown may help flatten coronavirus curve in india, says study -business today we are thankful to dr. mili shah for language check of our manuscript. key: cord-018106-5giapmcf authors: levin, jacqueline title: mental health care for survivors and healthcare workers in the aftermath of an outbreak date: 2019-05-16 journal: psychiatry of pandemics doi: 10.1007/978-3-030-15346-5_11 sha: doc_id: 18106 cord_uid: 5giapmcf when pandemics sweep across communities, they leave behind tremendous suffering in their wake. it is not only the illness that becomes a pandemic, but the same can be inferred about fear, mourning, and despair. the reverberations of loss are felt in a multitude of ways by those left behind. often times, the mental health issues of affected persons and entire communities do not receive the attention they deserve in the light of other competing, immediate needs imparted by the devastation of the pandemic. this chapter aims to develop strategies for providing psychiatric care to survivors and their families, in the aftermath of a pandemic outbreak. lastly, special considerations in the application of psychopharmacological interventions are reviewed. antibiotics and primary excision of the abscess may still result in persistent psychiatric symptoms. in cases of viral encephalitis, psychiatric symptoms are very common in the acute phase and recovery, especially mood disorders. major disability can result, including symptoms of depression, amnestic disorders, hypomania, irritability, and disinhibition (sexual, aggressive, and rageful) even months after recovery. psychosis may also rarely result. standard treatments with antidepressants, stimulants, mood stabilizers, neuroleptics, and electroconvulsive therapy should be applied [1] . individuals may suffer potentially permanent cognitive deficits secondary to illness or its treatments that will require cognitive rehabilitation. in cases of delirium, if the resultant encephalopathy is severe or persistent, pharmacologic interventions with antipsychotics (such as haloperidol 0.5-20 mg/ day) and mood stabilizers (such as valproic acid up to 60 mg/kg/ day) should be considered. in addition, psychosocial interventions will need to be implemented to maintain safety and care for someone who may no longer be able to care for themselves. additional consideration on this topic is provided in the chapter entitled neuropsychiatric sequelae of infectious outbreaks. in the wake of an infectious disease outbreak, the loss of functioning imparted by illness may leave survivors feeling demoralized, helpless, and in a state of mourning over the loss of the person they used to be. if the patient experiences marked distress or significant impairment in social or occupational functioning, they may meet dsm-v criteria for adjustment disorder. therapeutic interventions in those instances should focus on helping individuals regain a sense of autonomy and mastery through rehabilitation. it is helpful to focus on gaining immediate control over some specific aspects of their lives, as well as helping the persons identify and link with agencies and supports in the community [2] . psychotherapy, both individual and group therapy, if available, can help survivors come to terms with the loss of functioning. if the patient is left with significant depressive symptoms meeting dsm-v criteria for major depressive disorder, the psychopharmacological approach may be warranted; selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors should be considered in such cases. concurrent insomnia may be treated with melatonin, trazodone, ramelteon, or any available sedatives-hypnotics. prescribers should be aware of drug-drug interactions and cytochrome p450 interactions between selected psychotropics and medications prescribed by infectious disease physicians in treating survivors. patients who are at increased risk of developing delirium (i.e., elderly, dementia, and brain disease) should also be monitored for changes in mental status, attention, alertness, and orientation. psychotherapy (cognitive behavioral therapy, supportive psychotherapy, and psychodynamic psychotherapy) may also be of clinical benefit if available. enlisting local cultural and spiritual leaders may also help build hope and confidence. another important consideration is that proximity to and survival from life-threatening events (in this case illness) are known risk factors for the development of trauma-based disorders, including acute stress disorder and posttraumatic stress disorder (ptsd). ptsd is characterized by intrusive thoughts, nightmares, and flashbacks of past traumatic events, avoidance of reminders of trauma, hypervigilance, and sleep disturbance leading to significant social, occupational, and interpersonal dysfunction. in the aftermath of pandemics, increased psychiatric screening and surveillance is recommended to address acute stress disorder, posttraumatic stress disorder, depressive disorders, and substance abuse. in the short-term aftermath, psychological first aid can be administered to patients by public health and public behavioral health workers. such interventions focus on establishing a respectful, supportive rapport, triaging critical needs, normalizing stress and grief reactions, supporting positive thoughts about the future, and teaching mindfulness-based techniques to decrease the levels of stress and hyperarousal (i.e., deep breathing, progressive muscle relaxation, and guided imagery). normalizing angry feelings while decreasing anger-driven behaviors can also play a therapeutic role [2] . in the long-term aftermath of a pandemic, trauma-focused therapies and pharmacological treatments may be indicated. once a diagnosis of ptsd is made, treatment should be initiated promptly. first-line treatment consists of traumafocused cognitive behavioral therapy (cbt) to help reduce pessimistic and catastrophic thoughts about the future. exposure therapy and eye movement desensitization and reprocessing (emdr) therapies may also be utilized. if these therapeutic modalities are not readily available, selective serotonin reuptake inhibitors (ssris) and serotonin-norepinephrine reuptake inhibitors (snris) can also be considered first-line treatments, to be administered for a duration of at least 6-12 months to prevent recurrence and relapse. monotherapy or adjunctive therapy with quetiapine may also be considered. alpha-adrenergic receptor blockers such as prazosin could be used for sleep disruption and nightmares, either alone or in conjunction with an antidepressant [3] . special consideration should also be given to individuals with preexisting mental health issues who may experience setbacks, relapses, and impairments in functioning. more vulnerable patients with serious and persistent mental disorders such as primary psychotic illnesses or developmental disorders are likely to experience destabilizing disruptions in routine and access to medications/treatments. psychotic, manic, or depressive symptoms may be intensified due to stress; increasing standing psychotropic medications may be indicated. preexisting anxiety and substance use disorders are likely to worsen in the face of constant fear and distress. it is helpful to provide patients with a supply of prn or "asneeded" extra tablets of antipsychotics or benzodiazepines as the pandemic unfolds to treat worsening symptoms. it is also prudent to enlist these patients' families and social supports to warn them of the risk for psychiatric destabilization and provide them with specific examples of worsening psychiatric symptoms to be on the lookout for. a safety plan and communication strategy should be developed with the patient and his or her family in the aftermath of a pandemic, with attention paid to potential barriers imposed by the pandemic (i.e. pharmacy closures, difficulty accessing medications). when possible, it may be prudent to prescribe a few months' additional supply of medications to be entrusted to a reliable family member. increased monitoring is prudent in the aftermath of a pandemic with bimonthly or even weekly visits, depending on the severity of illness. for patients who are unable to access their usual providers, telepsychiatry can be a helpful substitute where available. mental health professionals should be trained in the assessment of suicidality and safety concerns which may arise in the setting of acute anxiety, disability, bereavement, and multiple losses. as a special consideration, it is worth noting that survivors of pandemics may find themselves the targets of pronounced stigma and rejection by their local communities. affected individuals may blame themselves, and they may be prevented from returning to their homes or workplaces [4] . entire cultural groups, communities, and geographic populations may become targets of stigmatization, which may serve as a barrier to seeking care [5] . in these cases, validating the experience of the stigmatized person is of utmost importance. in some communities, survivors of pandemics have been lauded as heroes by nongovernmental agencies in an attempt to decrease stigma [4] . fostering resilience in such persons and their communities can help them to reclaim a sense of self-efficacy and fortitude in the face of adversity [6] . just as patients experience significant emotional impacts in the course of a pandemic, so too will the brave and selfless healthcare personnel who are charged with the responsibility of providing aid to the infected. their burden, however, is compounded by their high and persistent risk for exposure and death, separation from their loved ones which may be either enforced or due to prolonged work shifts, seeing traumatic images of their disfigured or dying patients, working during surge conditions in overburdened settings with chronically scarce supplies and medications/vaccines, experiencing hopelessness due to massive human losses in spite of their best efforts to provide care, managing human remains, experiencing workforce quarantine, witnessing the death of their colleagues, lack of reinforcements and replacements, and their own fatigue and burnout, to name a few of the many traumas they must endure in the course of their service [7] . it, therefore, does not come as a surprise that studies of nurses who treated sars patients during the 2003 outbreak indicated high levels of stress and 11% rates of traumatic stress reactions, including depression, anxiety, hostility, and somatization symptoms [8] . one study showed that even 1 year after the sars outbreak in 2003, healthcare worker sars survivors still had persistently higher levels of stress and psychological distress than non-healthcare worker sars survivors [9] . similar findings have been reported in multiple studies indicating acute and persistently elevated stress levels as well as other emotional sequelae of healthcare workers during and after pandemic disease outbreaks [10] [11] [12] . those findings indicate that left unaddressed, emotional needs and wounds of healthcare personnel grappling with an outbreak can reverberate long, perhaps for many years, after an outbreak has abated. healthcare personnel working at great personal peril will, therefore, require frequent and clear communication regarding the status of the pandemic and developments as they unfold. communication at every level should be monitored, with systems in place to bidirectionally transmit news among healthcare workers, their administration, healthcare facilities, and the government [10] . leadership, structure, and clear delineation of duties and responsibilities are critical. determining staffing needs and establishing predictable schedules will lay a stable foundation for healthcare workers and ground them in the face of other destabilizing forces. healthcare workers on the frontlines should be supported to the fullest extent possible as the pandemic unfolds to prepare for what is to come. educational materials should be developed and provided that can outline what healthcare workers might expect in the course of their duties, including common reactions and stressors they may encounter from the public, patients, their friends and families, or from within themselves. this is of utmost importance, as an unprepared workforce may feel afraid to serve; in a survey of over 6400 healthcare workers across 47 facilities in the new york metropolitan region, only 48.4% said they would be willing to report to work during an outbreak of sars, most frequently citing fear for personal or family safety as the reason they were unwilling to work [13] . given the real and understandable fear of contracting illness, comprehensive and repeated training on infection control and how to use personal protective equipment can help increase the confidence of the workforce that their personal safety will be maintained. healthcare personnel should also be offered periodic health assessments to reassure them of their physical well-being [8] . preparations should also center on immunization programs, available vaccines for frontline healthcare personnel, availability of prophylactic medications, and assurances that their concerns and needs will be heard and met [14] . a study of the psychological impact of the 2003 sars outbreak on healthcare workers in singapore found that support from supervisors and colleagues was a significant negative predictor for psychiatric symptoms and ptsd, in addition to clear communication of directives and precautionary measures which also helped reduce psychiatric symptoms [15] . buddy systems pairing more and less experienced healthcare workers can help not only to transfer skills, but also to reduce social isolation and promote a sense of support and interconnectedness [10] . the experience of being a healthcare worker during a pandemic is both isolating and stigmatizing; having a partner to share the experience with would be beneficial on multiple levels. administrators can improve the situation by being attentive to the psychological, physical, spiritual, and psychosocial needs of healthcare workers. systems should be implemented for rest and relief of duties to prevent burnout; it is also prudent to limit overtime [2] . programs promoting well-being incorporating mindfulness and relaxation techniques can help healthcare workers develop self-help skills during times of increased stress; once learned, they may also be able to pass such skills on to their patients. workforce resilience programs and self-care strategies should be promoted. teamwork and morale-building activities should also be promoted, as well as wellness breaks. it may also be meaningful to plan staff-appreciation events and verbally acknowledge their ongoing efforts [2] . spiritual leaders from the faith-based community may also be called upon to provide spiritual guidance to affected healthcare workers who would find tremendous comfort in such an outlet. it is also important to remember that healthcare workers will have their own sick family members, childcare issues, and personal affairs impressing upon them from the outside world, which can leave them feeling pulled between a sense of duty to their patients and their loved ones. psychosocial programs that are mindful of providing services for the families of healthcare workers can go a long way in supporting staff and protecting morale. lending cellular phones, laptops, or tablets to healthcare workers and their families to ensure they are able to maintain ongoing communication, as well as providing updates on websites and hotlines, can also help healthcare workers feel they are still interconnected with their families and may alleviate some of the real pressures that are felt. furthermore, healthcare workers should be regularly reminded and trained in infection control measures when they return home; for example, reminding staff of handwashing and to change clothes before entering their homes to protect family members. providing disposable scrubs or garments especially for wear in the hospital may also help decrease healthcare workers' anxiety about transmitting illness to their families back home [2] . it may also help to designate healthcare workers a specialized status within the community, given the crucial public service role they play. for example, providing specialized identification cards that might prevent them from waiting in lines at gas stations or supermarkets, as well as fair compensation and a stipend for their families, may further promote a sense of professional pride and goodwill and may help counteract the negative impact of the stigma that they may endure. lastly, employee assistance programs should target healthcare personnel who have developed traumatic, affective, or anxiety disorders as well as those struggling with increased substance use disorders. increased mental health monitoring is advised, given healthcare workers' proximity and repeated exposure to traumatic experiences, as well as the welldocumented evidence of the persistent distress they are likely to experience. they should be considered a high-risk group for developing psychopathology in the aftermath of a pandemic and they should be given the same consideration and nurturing of any other high-risk population identified. healthcare workers should have ready access to psychiatric care, pharmacologic interventions, and both individual and group psychotherapy. they should be reassured that their families will receive the same. practitioners tasked with treating patients in the aftermath of a pandemic will face challenges in providing standard care, both due to infrastructural and crisis-related adversities, as well as secondary to unique biological changes imparted by the disease itself. it is important for practitioners to be aware of common drug interactions, dosing, and titration strategies, and special considerations for different classes of psychopharmacological agents used. this section aims to review and summarize pertinent aspects of psychopharmacological agents which may be of use to future practitioners who find themselves providing psychiatric care in the wake of a pandemic. antidepressants are first-line agents for a number of psychiatric conditions that may be encountered in the aftermath of a pandemic. such diagnoses include mood disorder secondary to a general medical condition, major depressive disorder, posttraumatic stress disorder, dissociative disorder, obsessive-compulsive disorder, and generalized anxiety disorder, to name a few. to identify and treat major depressive disorder, the psychiatric interview should focus on the psychological symptoms of depression (i.e., sad mood, anhedonia, hopelessness, worthlessness, guilt, and suicidality) rather than the vegetative symptoms (i.e., sleep disturbance, appetite change, psychomotor changes, and decreased concentration and energy), which may be of lower yield in the setting of acute medical illness. depression should also be distinguished from hypoactive delirium, which may also present with diminished appetite, sleep disturbance, and an appearance of apathy (in the case of delirium, treatment with antipsychotics will be more effective than addition of an antidepressant). an adequate trial of an antidepressant is defined as 12 weeks of antidepressant therapy at an effective therapeutic dose. it is helpful to establish expectations with patients by reminding them that daily use is important (rather than asneeded use), that symptoms may take 2-4 weeks before they begin improving, and that common side effects such as nausea, diarrhea, headache, and sexual dysfunction may be expected. patients age 24 and younger should be monitored for worsening suicidal ideation. for patients with significant concurrent anxiety, a slow titration may be most appropriate with temporary use of benzodiazepines until the antidepressant takes clinical effect (e.g., lorazepam 0.5-1 mg orally two to three times per day). if the drug is not working within 6-8 weeks, the patient may require a dose increase or a switch should be considered. providers should treat until remission or a significant reduction in symptoms is observed, continuing treatment for 1 year for the first episode of major depressive disorder and indefinitely if there have been two or more episodes. there are six principal selective serotonin reuptake inhibitors in common use: fluoxetine, sertraline, citalopram, escitalopram, paroxetine, and fluvoxamine. the global accessibility of these agents may vary. fluoxetine has a dose range from 10 to 80 mg and has the longest half-life (2-3 days), which makes it an ideal choice for patients in whom there are concerns for compliance or consistent access to medication. sertraline has a dose range of 25-200 mg, and its wide range of dosing making it a good choice for elderly patients or for those who may be sensitive to side effects. fluoxetine and sertraline have no renal dose adjustment, but a lower or half dose is recommended for patients with hepatic impairment. citalopram doses range from 10 to 40 mg, but should not exceed more than 20 mg/day for patients over age 60 or if the hepatic impairment is present. there is no dose adjustment for mild/ moderate renal impairment, but caution should be used in severe impairment. it is important to note that citalopram should not be combined with other qtc prolonging agents (applies to antimicrobials such as erythromycin, clarithromycin, fluoroquinolones, antifungals, and antimalarials) for increased risk of torsades de pointes [16] . escitalopram, an enantiomer of citalopram, has dose ranges from 5 to 20 mg, should not exceed more than 10 mg/day in the elderly or in cases of hepatic impairment, or if severe renal impairment is present. paroxetine doses range from 20 to 40 mg, with only 10 mg/day recommended in cases of renal or hepatic impairment. it has the shortest half-life of all the ssris (21 hours), resulting in an uncomfortable discontinuation syndrome and may not be ideal for patients with interrupted access to care/ medications. side effects of sedation, weight gain, constipation, and dry mouth may make it a favorable option, however, for specific patients. lastly, fluvoxamine doses range from 100 to 200 mg; however, many drug-drug interactions are associated with its use and should be monitored for. clinically significant interactions exist between selective serotonin reuptake inhibitors and several antiretrovirals in the setting of hiv/aids. for example, ssris shown to have decreased metabolism in the setting of ritonavir include sertraline and citalopram, but alternatively, the levels of fluoxetine and fluvoxamine are both decreased by nevirapine. fluoxetine and fluvoxamine can both increase the levels of amprenavir, delavirdine, efavirenz, indinavir, lopinavir/ritonavir, nelfinavir, ritonavir, and saquinavir [17] . tricyclic antidepressants have common side effects such as drowsiness, confusion, dizziness, weight gain, hypotension, and tachycardia, as well as anticholinergic side effects including dry mouth, blurred vision, decreased gastrointestinal motility, and urinary retention. some of these side effects can be taken advantage of in the setting of hiv/aids, specifically weight gain, increased sleep, and decreased diarrhea [17] . mirtazapine 7.5-45 mg at bedtime similarly may be a good choice in patients with postinfectious cachexia and exhaustion as it promotes weight gain and can cause a significant sedation, making it suitable for patients suffering from insomnia. bupropion 75-450 mg/day can be helpful in postinfectious anergia, but prescribers should bear in mind that it lowers the seizure threshold. tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors are useful if there is also concurrent neuropathic pain or a lingering inflammatory process that persists following some viral infections; for example, amitriptyline 10-400 mg at bedtime, duloxetine 60-120 mg/day, or venlafaxine 75-225 mg/day. antimicrobial drugs themselves have had prominent associations with delirium and a host of other psychiatric side effects. for example, antibacterials such as quinolones have been associated with psychosis, paranoia, mania, agitation, and tourette-like syndrome, and procaine penicillin has been associated with delirium, psychosis, agitation, depersonalization, and hallucinations. mefloquine and other antiparasitic/ antimalarial drugs have been associated with confusion, psychosis, mania, depression, aggression, anxiety, and delirium. antituberculous drugs such as cycloserine have been associated with agitation, depression, psychosis, and anxiety. antivirals such as amantadine have been associated with psychosis and delirium, and interferon treatment is frequently associated with depression [1] . in addition to being cognizant of the side effects of the treatments themselves, drug-drug interactions between antimicrobials and psychotropic drugs abound. psychiatric care providers should exercise caution when utilizing specific psychotropics (i.e., antipsychotics or tricyclic antidepressants) in the setting of other qtc interval-prolonging agents such as erythromycin or ketoconazole, due to increased risk of ventricular arrhythmias and torsades de pointes. providers should keep in mind that linezolid is an irreversible monoamine oxidase-a inhibitor and isoniazid is a weaker monoamine oxidase inhibitor-so the serotonin syndrome or hypertensive crisis can result if serotonergic antidepressants or other sympathomimetics (such as meperidine, which is an opioid analgesic) are coadministered. antimalarials have been shown to increase the levels of phenothiazine neuroleptics. clarithromycin and erythro-mycin can increase carbamazepine, buspirone, clozapine, alprazolam, and midazolam levels. quinolones may increase clozapine and benzodiazepine levels but reduce benzodiazepine effect via the gaba receptor. lastly, providers should be aware that isoniazid can increase haloperidol and carbamazepine levels [1] . psychiatric care providers should be aware of the myriad complications of corticosteroid use, seen in up to 6% of patients presenting with significant neuropsychiatric manifestations. anxiety, mania, delirium, or psychosis may present with the administration of corticosteroids, and a dosedependent relationship has been observed. in most cases, a reduction of corticosteroid dose will improve symptoms; however, if this strategy is not possible or ineffective, antipsychotics or mood stabilizers should be used [18] . in patients presenting with predominantly manic symptoms, special consideration should be given to medical comorbidities when selecting a mood stabilizer. lithium may be difficult to administer in the setting of renal dysfunction, electrolyte abnormalities, or fluid shifts. valproic acid may be relatively contraindicated in patients with significant liver disease or pancreatitis. carbamazepine has antidiuretic actions, has quinidine-like effects on cardiac conduction, and has been associated with aplastic anemia and leukopenia which prescribers should bear in mind. providing psychiatric care to survivors and healthcare workers in the aftermath of a pandemic outbreak is a complicated, but crucial, imperative in the service of reducing the burden of human suffering. challenges will abound on multiple levels, but there is no substitute for preparedness. knowledge of assessment, differential diagnosis, medical complications, and treatment will aid the psychiatric care provider in developing a treatment approach for these patients who are most vulnerable during their greatest time of need. chapter 27: infectious diseases. in: levenson j, editor. textbook of psychosomatic medicine colorado: the colorado department of human services division of mental health pharmacotherapy for posttraumatic stress disorder in adults ebola's mental-health wounds linger in africa an "epidemic within an outbreak:" the mental health consequences of infectious disease epidemics neill institute for national & global health law blog pandemic influenza plan: psychosocial services preparedness institute for disaster mental health at suny new paltz and new york learns public health psychological distress of nurses in taiwan who worked during the outbreak of sars stress and psychological distress among sars survivors 1 year after the outbreak impact on health care workers employed in high-risk areas during the toronto sars outbreak psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in singapore immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers health care workers' ability and willingness to report to duty during catastrophic disasters can the health-care system meet the challenge of pandemic flu? planning, ethical, and workforce considerations psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in singapore drug induced qt prolongation and torsades de pointes choosing antidepressants for hiv and aids patients: insights on safety and side effects the neuropsychiatric complications of glucocorticoid use: steroid psychosis revisited key: cord-346606-bsvlr3fk authors: siriwardhana, yushan; gür, gürkan; ylianttila, mika; liyanage, madhusanka title: the role of 5g for digital healthcare against covid-19 pandemic: opportunities and challenges date: 2020-11-04 journal: nan doi: 10.1016/j.icte.2020.10.002 sha: doc_id: 346606 cord_uid: bsvlr3fk covid-19 pandemic caused a massive impact on healthcare, social life, and economies on a global scale. apparently, technology has a vital role to enable ubiquitous and accessible digital health services in pandemic conditions as well as against “re-emergence” of covid-19 disease in a post-pandemic era. accordingly, 5g systems and 5g-enabled e-health solutions are paramount. this paper highlights methodologies to effectively utilize 5g for e-health use cases and its role to enable relevant digital services. it also provides a comprehensive discussion of the implementation issues, possible remedies and future research directions for 5g to alleviate the health challenges related to covid-19. the recent spread of coronavirus disease (covid19) due to severe acute respiratory syndrome coronavirus 2 (sars-cov-2) [1] has caused substantial changes in the lifestyle of communities all over the world. by the end of june 2020 at the time of this writing, over eleven million positive cases of covid-19 were recorded, causing over 500,000 deaths. countries have been facing a number of healthcare, financial, and societal challenges due to the covid-19 pandemic. overwhelmed healthcare facilities due to rapid growth of new covid-19 patients, are experiencing interruptions in provision of regular health services. moreover, healthcare personnel are also becoming vulnerable to covid-19 and this is taxing the healthcare resources even more. to cease the wide spread of the virus, governments impose strict restrictions and control on travel within and between countries, negatively affecting the economies. while the remote work was considered as an alternative with limitations, certain jobs became obsolete. the increased unemployment is a burgeoning problem even for strong economies. apart from that, government expenditure on unemployed workforce, losing income from sectors associated with tourism such as airlines, hotels, local transport, and entertainment were major challenges for the economies. governments had to introduce new guidelines on social distancing to prevent the spread of the virus. this resulted in closing schools, isolating cities and even restricting public interactions, affecting the regular lifestyle of people. such disruption could lead to unprecedented _______________________ *corresponding author email addresses: yushan.siriwardhana@oulu.fi (yushan siriwardhana), gueu@zhaw.ch (gürkan gür), mika.ylianttila@oulu.fi (mika ylianttila), madhusanka.liyanage@oulu.fi, madhusanka@ucd.ie (madhusanka liyanage) consequences such as losing physical and mental well-being. maintaining the societal well-being during the covid-19 era is therefore a daunting task. the technological advancement is one of the key strengths in the current era to overcome the challenging circumstances of covid-19 outbreak. the timely application of relevant technologies will be imperative to not only to safeguard, but also to manage the post-covid-19 world. the novel ict technologies such as internet of things (iot) [2] , artificial intelligence (ai) [3] , big data, 5g communications, cloud computing and blockchain [4] can play a vital role to facilitate the environment fostering protection and improvement of people and economies. the capabilities they provide for pervasive and accessible health services are crucial to alleviate the pandemic related problems. 5g communications present a paradigm shift from the present mobile networks to provide universal high-rate connectivity and a seamless user experience [5] . 5g networks target delivering 1000x higher mobile data volume per area, 100x higher number of connected devices, 100x higher user data rate, 10x longer battery life for low power massive machine communications, and 5x reduced end-toend (e2e) latency [6] . these objectives will be realized by the key technologies such as mmwaves, small cell networks, massive multiple input multiple output (mimo) and beamforming [7] . by utilizing these technologies, 5g will mainly support three service classes i.e. enhanced mobile broadband (embb), ultra reliable and low latency communication (urllc) and massive machine type communication (mmtc). the novel 5g networks will be built alongside fundamental technologies such as software defined networking (sdn), network function virtualization (nfv), multi-access edge computing (mec) and network slicing (ns). sdn and nfv enable programmable 5g networks to support the fast deployment and flexible management of 5g services. mec extends the intelligence to the edge of the radio network along with higher processing and storage capabilities. ns creates logical networks on a common infrastructure to enable different types of services with 5g networks. these 5g technologies will enable ubiquitous digital health services combating covid-19, described in the following section as 5g based healthcare use cases. however, there are also implementation challenges which need to mitigated for efficient and high-performance solutions with wide availability and user acceptance as discussed in section 3. in this work, we elaborate on these aspects and provide an analysis of 5g for healthcare to fight against the covid-19 pandemic and its consequences. capabilities of 5g technologies can be effectively utilized to address the challenges associated with covid-19 presently and in the post covid-19 era. existing healthcare services should be tailored to fit the needs of covid19 era while developing novel solutions to address the specific issues originated with the pandemic. in this section, the paper discusses several use cases where 5g is envisaged to play a significant role. these use cases are depicted in figure 1 and the technical requirements of use cases are outlined in table 1 . telehealth is the provision of healthcare services in a remote manner with the use of telecommunication technologies [8]. these services include remote clinical healthcare, health related education, public health and health administration, defining broader scope of services. telemedicine [9] refers to remote clinical services such as healthcare delivery, diagnosis, consultation, treatment where a healthcare professional utilizes communication infrastructure to deliver care to a patient at a remote site. telenursing refers to the use of telecommunication technologies to deliver nursing care and conduct nursing practice. telepharmacy is defined as a service which delivers remote pharmaceutical care via telecommunications to patients who do not have direct contact with a pharmacist. (e.g. remote delivery of prescription drugs). telesurgery [10] allows surgeons to perform surgical procedures over a remote distance. all these healthcare related teleservices are highly encouraged in post-covid-19 period due to multiple reasons. lack of resources (i.e., hospital capacity, human resources, protective equipment) in healthcare facilities due to existing covid-19 patients, social distancing guidelines imposed by authorities, requirements of maintaining the regular healthcare services adhering to the new guidelines imposed by the healthcare administrations and the need to minimize the risk of healthcare professionals getting exposed to covid-19 are factors motivating teleservices related to healthcare. these teleservices sometimes have strict requirements and call for sophisticated underlying technologies for proper functionality. as an example, a telemedicine followup visit between the patient and the doctor, would require 4k/8k video streaming with low-latency and low jitter. telehealth based remote health education programs should be accessible to the students from anywhere via an internet connection having a proper bandwidth. monitoring the patients via telenursing also requires uninterrupted hd/4k video stream between the patient and the nurse. remote delivery of drugs is possible via unmanned ariel vehicles (uav), which requires assured connectivity with the base station to send/receive control instructions without delays. extreme use cases like telesurgery requires ultra-low latency communication (less than 20 ms e2e latency) between the surgeon and the patient, connectivity between number of devices such as cameras, sensors, robots, augmented reality (ar) devices, wearables, and haptic feedback devices [11] . the future 5g networks will use the mmwave spectrum, which leads to the deployment of ultra-dense small cell networks, including the network connectivity for indoor environments. technologies like massive mimo combined with beamforming will contribute for providing extremely high data rates for large number of intended users. these technologies together provide a better localization for indoor environments [12] . these 5g technologies realize the embb service class which facilitates the transmission of 4k/8k videos between the healthcare professional and the patient, irrespective of the location of access. the new radio access technology developed by the 5g networks, also known as 5g new radio (nr) supports urllc. the urllc service class helps to realize the ultra-low latency requirements of telesurgery applications. a local 5g operator (l5go) has its core and access network deployed locally on premises, serves the healthcare facility with multiple base stations deployed both outdoors and indoors to provide connectivity for case specific needs. this deployment is beneficial for telesurgery use case to achieve ultra-low latency, given that there is a requirement of surgeon and patient being in separate rooms due to the pandemic situation. mec servers deployed at the 5g base stations can be utilized to deploy the control functions for uavs for proper payload deliveries. the fundamental design changes in 5g networks will enable the communication of large number of iot devices, which usually transfer less data compared to human activities such as streaming. these mmtc services provide the support to 5g enabled medical iots (miots) that can be used to monitor and treat remote patients. mmtc will connect and enable communication between heterogeneous devices into the 5g network so that they can operate in synchronicity. a sensor in a wearable device of the patient can immediately sends a signal to the remote nurse via 5g network so that the nurse can activate a special equipment in the patient's room using the mobile device. the use of 5g technologies in a hospital environment for telehealth use cases is illustrated in figure 2 . the spread of covid-19 disease demands the rapid launching of new healthcare services/applications, change the way present healthcare services are provided [13] , integrate modern tools such as ai and machine learning (ml) in the data analysis process [14] . a new application can collect the data of covid-19 patients from different healthcare centers, upload the data to a cloud server and make the information available to public so that others can rely on the information for different purposes. a live video conferencing based interactive applications which enable healthcare professionals to discuss with patients and help them is another example [15] . other applications would perform regular health monitoring of patients such as followup visits, provide instructions on medical services, and spread knowledge on present covid-19 situation and upto date precautions. the difficulty during the pandemic was that there was a need to automate most of the regular work to minimize the interaction between people and new application development needs were also sudden. this calls for a flexible network infrastructure which supports the development of such applications within a short period of time. in contrast to the present 4g networks, 5g supports the creation of new network services as softwarized network functions (nfs) by utilizing sdn and nfv technologies. these nfs can be hosted at the cloud servers, operator premises, or in the edge of the network based on the application demands. mec servers equipped with storage and computing power and reside at the edge of the radio network, will be a suitable platform to host these applications. the deployment of such applications will be more flexible in 5g networks because of the sdn and nfv. bringing the nfs towards the edge eliminates the dependency of the infrastructure beyond the edge, making the applications more reliable. increasing the capacity of the 5g network is much easier because the network itself is programmable. 5g networks are capable of deploying network slices which create logical networks to cater the services with similar type of requirements such as iot slice and low latency slice, thereby serving applications with guaranteed service levels. a surge in demand for personal protective equipment (ppe), ventilators and certain drugs was observed at the beginning of the covid-19 spread, causing an imbalance of the regular supply chains [16] . manufacturing plants were unable to maintain the regular production due to the shortage of raw materials and labor force, therefore they were not capable of responding to the increased demand for the goods. the supplies of finished products were also delayed due to transport restrictions and there were no proper alternative distribution mechanisms so that the people who are really in need would receive them. n95 masks, hand sanitizers, and regular medicine are some of the goods where this imbalance of supply was often seen. those who reacted quickly could stock items in surplus while others who are in need did not receive them. donations to the victims were not always distributed in a fair manner because of the absence of centralized management systems. delivery of the items to the final consumer was a concern due to the risk of covid-19 spread and the restrictions imposed by the authorities to limit the physical contact. it is a challenge for the governments, healthcare authorities, distributors to implement proper mechanisms to manage the supply chains of healthcare items in the covid-19 period. to address the issues in healthcare related supply chains, industries can adopt smart manufacturing techniques equipped with iot sensor networks, automated production lines which dynamically adapt to the variations in demand, and sophisticated monitoring systems. iot based supply chains could be used to properly track the products from the manufacturing plant to the end consumer, i.e. connected goods. uav based automated delivery mechanisms are specially suited in the covid-19 situation to deliver medicine, vaccines, masks to the end consumer minimizing the physical contact. 5g supports direct connectivity for iot and mmtc between iot devices. this will fuel the possibility to use large amount of iot devices to increase the efficiency of supply chains. deployment l5gos to serve the needs of industries is a better way to integrate iot sensors, actuators, robots directly into 5g network enabling a 5g based smart manufacturing system. the proper network connectivity for the sensors, actuators, robots in the manufacturing plants will be enabled by the mmwave 5g small cells deployed indoors. massive mimo will provide connectivity for a large number of devices and beamforming technique ensures a better quality of the network connection. the direct connectivity of goods into the 5g systems makes the supply chains more transparent. mec integrated with 5g, can be used to process the data locally to improve the scalability of the systems as well as security and privacy of collected data. moreover, mec integrated with 5g can easily be used to implement decentralized solutions via blockchain [17] , [18] . the delivery of items to the final destination can be performed via beyond lineof-sight (blos) uav guided by the 5g network. this could minimize unnecessary interactions in covid-19 period and reduce human efforts. real-time data is available for the authorized users for monitoring and tracking, which increases the transparency of the operation. covid-19 positive patients with mild conditions are usually advised for self-isolation to prevent further spread. while self-isolation is a better alternative to manage the capacity of healthcare facilities, the self-isolating individuals should be properly monitored to make sure that they follow the self-isolation guidelines. the challenge is to track every movement of the patient, which is currently impossible. in an event of a violation of self-isolation guidelines, control instructions should be sent. mobile device based selfisolation monitoring is possible via an application which sends random gps data of patient's mobile phone to a cloud server. wearable devices attached to the patient's body use their sensors to measure the conditions of the patient and upload the data via the mobile phone. uav based solutions can monitor the conditions of the patients from a distance. uavs can monitor body temperature via infrared thermography and identify the person via face recognition algorithms. moreover, contact tracing of identified positive cases is extremely important [19] . however, present contact tracing mechanisms involve significant human engagement and consist of a lot of manual work. this prevents the identification of all the possible close contacts and hinders the effectiveness of the contact tracing. manual tracing does not guarantee that all the possible close contacts are identified. bluetooth low energy (ble) based contact tracing applications use ble wearable devices, which advertise its id periodically so that other compatible devices in close proximity can capture the id and store with the important details such as timestamp, gps location data (optionally). once an infected covid-19 patient is detected, the ble solution provides the ids of the close contacts over a defined period. ble based solutions identify the contacts in the range of few meters, whereas pure gps based solutions do not have that accuracy. role of 5g mmtc in 5g is responsible for massive connectivity of heterogeneous iot devices such as sensors, wearables, and robots. the small cell networks equipped with mimo and beamforming in 5g will ensure better connectivity and positioning including indoor environments. hence, iot devices directly connected to 5g network can be effectively used to monitor the compliance of self-isolation. instead of using general mobile device data, the patients can be attached with a low power wearable devices which transfer data via ble technology. those sensory data can be updated to the cloud via the 5g network and the authorized parties can monitor the behavior of the patient. a similar concept can be applied to contact tracing where the wearable ble devices collect data of nearby devices and upload to the cloud via 5g network. once a patient is tested positive, all the close contact details are already in the cloud and they are notified for proper safety measures such as self-isolation. mec servers deployed at the 5g base stations are useful to increase the scalability of the operation as the resource demand increases. allocating a separate network slice for contact tracing data transfer is a better approach to assure the quality of service (qos) and strengthen the privacy and security of the data. despite the use-cases for 5g concerning healthcare and the fight against covid-19, there are also imminent challenges ranging from technical ones such as scalability to socio-economic ones including technology acceptance. the impact of pertinent deployment challenges on each use case is depicted in table 2 . j o u r n a l p r e -p r o o f journal pre-proof a video recording of a telemedicine session may contain personal information which the patient would like to disclose only to the doctor. in addition, automated contact tracing applications aggregate sensitive location data without the owners' knowledge. sharing such sensitive user data with unauthorized parties such as third-party advertisers is a serious privacy violation [27] . in addition, privacy protection is a legal requirement, which is posed by various legal frameworks such as gdpr [28] and health insurance portability and accountability act (hipaa) [29] . to address the privacy challenge, solutions like privacy by-design [30] , software defined privacy [31] have to be deployed with 5g health applications already at the design phase. privacy-by-design relies on the notion that that data controllers and processors should be proactive in addressing the privacy implications of any new or upgraded system, procedure, policy or data-sharing initiative, not at the later stages of its life-cycle, but starting from its planning phase [32] . the developed e-health solutions in 5g should consider the entire life-cycle of health data when protecting to protect privacy, access control methods managing how different parties access information are necessary. edge computing is beneficial to minimize data transmissions through different network elements and enable local processing, improving privacy aspects [33] . furthermore, users of e-health technology should be made fully aware of what they are consenting to regarding data sharing and processing when they are using such digital solutions. similarly, transparency in the form of informing users of potential privacy risks are effective to improve the adoption of e-health solutions [34] . attempts by adversaries to attack the databases containing sensitive information pose security risks. the importance of e-health systems exacerbates the impact of attacks on the availability requirement. the integration of miot increases security risks of healthcare systems. such low-end devices are comparably easy to hack and vulnerable to denial-of-service (dos) attacks. massive amount of connected devices increases the number of entry points for attackers to perform unauthorized operations, i.e. increases the attack surface, on the healthcare system [35] . lightweight and scalable security mechanisms must be designed to secure miots. adequate security mechanisms are crucial to address the limited capabilities of constrained sensors, as well as the additional vulnerabilities if part of the security functions are offloaded to the cloud. for the digital health services, widespread automation, data analytics and smart control requires ml and ai techniques in 5g systems. encrypted data transmission and distributed security solutions such as blockchain can prevent attackers gain access to the network and protect the collected user data of different premises. the employed security mechanisms and algorithms should support continuous updates with minimal effort to adapt to discovered vulnerabilities and emerging security threats. regime a rapid deployment of new healthcare applications will add extra traffic as well as increase the number of 5g users who access such services. this will lead to increased network congestion. as an example, ar based applications used in telemedicine require high bandwidth and low latency. however, a congested network fails to satisfy the service levels for such applications. moreover, it is challenging to manage billions of miots. when a large number of iot devices generate ad-hoc data transfers, the network should be scalable to cope with the increased number of traffic events. the small data characteristics and intermittent connectivity of iot encumber the medium access and physical layers of access networks serving ehealth applications. ns in 5g with dynamic scalability is a possible solution to address this problem. the slices serve similar type of services and they can be made adaptive based on the various parameters such as priority of the service, present network traffic, available network resources, qos requirement, number of iot devices presently connected [36] . deployment of virtual nf based on demand at the mec servers will provide a solution to the congestion due to sudden increase of localized demands. for improving scalability, edge computing systems and distributed clouds can perform visual processing on large computational capabilities like gpus and transmit the audiovisual outputs enriched with analytics results to mobile e-health devices. in this way, the impact from device limitations is elastically minimized while congestion towards core network is also mitigated. regarding the physical layer, phy techniques such as full beamforming technologies using a large number of antenna elements increase scalability, high frequency utilization efficiency and high-speed communication. network operators need to deploy these 5g based solutions as soon as possible. the limited deployment of 5g networks and limited availability of 5g devices will be an immediate problem for many countries. undoubtedly, the 5g proliferation is expected to be gradual in terms of network connectivity and capacity. the complexity and implementation issues of 5g devices including power consumption due to high frequency transmissions as well as multi-band support of upper and lower frequency bands complicate the device cost and production challenges. governments and networks operators should push forward their deployment plans. moreover, small scale 5g deployments such as l5go networks [37] should be encouraged to use in hospitals, manufacturing plants [38] . purpose-built iot devices with a smaller but targeted capabilities for e-health use-cases can alleviate the complexity and cost issues regarding the deployment and commissioning of 5g systems. from the business perspective, offering a discount to mobile operators bidding in spectrum auctions in exchange for an improved coverage commitment can expedite the 5g deployment. for improving coverage in poorly served areas, some spectrum bands can be shared by different network providers. from the cost minimization perspective, ran sharing allows multiple operators to use the same radio access infrastructure and enables an easier coverage expansion for 5g. incidents such as destroying the cellular base stations [39, 40] due to conspiracy theories linking new 5g mobile networks and the covid-19 pandemic [41] , disrupts connectivity affecting the applications. however, network j o u r n a l p r e -p r o o f journal pre-proof connectivity and service continuity are critical for connected e-health solutions. 5g solutions may require the user to possess sophisticated level of technical literacy. however, many people lack such level of technical literacy. the provided ease of use is an important factor that supports or inhibits the implementation of e-health systems. health personnel is deterred from or resistant to using such new systems with additional complexity to their workflows, or requiring additional effort/time [42] . furthermore, 5g devices are significantly more expensive, leading to a cost burden on users. experts and media have responsibility to clear out these inaccurate social beliefs with the support of civil society and governments. the applications can be made easier to use and to execute on average hardware and devices so that everyone can afford it and use the services. for e-health solutions supporting physician-patient interaction, an effective clinical decision support system must minimise the effort required by clinicians to receive and act on system recommendations. this requirement is extended to include ease of use for patients and their family members and other service users, or even health professionals be-sides clinicians, such as nurses [42] . solutions for remote monitoring, contact tracing will result in legal issues unless the sensitive personal data is not properly handled. examples are contact tracing after the patient is recovered from covid-19, collecting and storing unnecessary data from the personal devices. since access to healthcare is a right, if the technical solutions prevent people from obtaining timely healthcare or cause wrong diagnosis/treatment, that is an issue concerning fundamental rights. 5g-enabled smart devices for e-health will have a far reaching impact on manufacturers, service companies, insurers and consumers. such a situation could also lead to legal issues. adhering to the policies defined by standardization bodies such as eu statement on contact tracing [43] prevents legal issues. standardisation and regulation must cover the whole range of healthcare technology chain from medical device technologies to software technologies, including sensors. obtaining legal advice before the deployment of different applications would also prevent the future legal issues. the traditional product liability limited to the form of tangible personal property should be extended to the correct functioning of network and services in e-health solutions. this is more challenging due to the complex environment of 5g. therefore, root-cause analysis techniques and pervasive monitoring functions are important [35] . healthcare sectors of the countries were the first to affect due to the spread of covid-19 disease, facing numerous challenges. as the countries now have control mechanisms in place to minimize the spread of covid19, they are reopening the economies so that the public can resume their regular lifestyle. to prevent any "re-emergence" of the disease, healthcare sectors of each country must be equipped with novel solutions to address any emerging j o u r n a l p r e -p r o o f challenges effectively. to this end, 5g technologies are crucial. 5g utilizes mmwave frequencies of the radio spectrum with small cell base stations which will provide better connectivity including indoor environments via its nr. massive mimo combined with beamforming will serve a large number of 5g devices/users with guaranteed data rates. these technologies deliver embb, urllc and mmtc service classes which enable the development of different types of services using 5g networks such as ar, uav communication, and collaborative robots. together with 5g, mec and ns will improve flexibility, scalability, guaranteed service levels and security for the applications. hence, solutions developed using 5g technologies serve various health related use cases such as telehealth, supply chain management, self-isolation and contact tracing, and rapid health services deployments. however, a wide range of implementation challenges such as privacy/security, scalability, and societal issues should be addressed before deploying such applications with full functionality. severe acute respiratory syndrome coronavirus 2 (sarscov-2) and corona virus disease-2019 (covid-19): the epidemic and the challenges smart home-based iot for real-time and secure remote health monitoring of triage and priority system using body sensors: multidriven systematic review role of biological data mining and machine learning techniques in detecting and diagnosing the novel coronavirus (covid-19): a systematic review a proposed solution and future direction for blockchain-based heterogeneous medicare data in cloud environment five disruptive technology directions for 5g scenarios for 5g mobile and wireless communications: the vision of the metis project what will 5g be? how about actively using telemedicine during the covid-19 pandemic? m-health solutions using 5g networks and m2m communications transformation in healthcare by wearable devices for diagnostics and guidance of treatment single-and multiple-access point indoor localization for millimeter-wave networks realtime smart patient monitoring and assessment amid covid19 pandemic-an alternative approach to remote monitoring ai-driven tools for coronavirus outbreak: need of active learning and cross-population train/test models on multitudinal/multimodal data design and develop a video conferencing framework for realtime telemedicine applications using secure group-based communication architecture lessons from operations management to combat the covid-19 pandemic the role of blockchain in 6g: challenges, opportunities and research directions, in: 2020 2nd 6g wireless summit (6g summit) how can blockchain help people in the event of pandemics such as the covid-19? a flood of coronavirus apps are tracking us. now it's time to keep track of them tactile-internetbased telesurgery system for healthcare 4.0: an architecture, research challenges, and future directions 5g mobile and wireless communications technology survey on multi-access edge computing for internet of things realization 2017 ieee 85th vehicular technology conference the efficacy of contact tracing for the containment of the 2019 novel coronavirus (covid-19) 5g technology for augmented and virtual reality in education telepharmacy services: present status and future perspectives: a review for telehealth to succeed, privacy and security risks must be identified and addressed eu data protection rules department of health & human services, health insurance portability and accountability act of 1996 (hipaa a systematic literature review on privacy by design in the healthcare sector 2016 ieee international conference on cloud engineering workshop (ic2ew) privacy by design: informed consent and internet of things for smart health privacy techniques for edge computing systems first, design for data sharing inspire-5gplus: intelligent security and pervasive trust for 5g and beyond networks dynamic network slicing for multitenant heterogeneous cloud radio access networks micro operators to boost local service delivery in 5g micro-operator driven local 5g network architecture for industrial internet mast fire probe amid 5g coronavirus claims at least 20 uk phone masts vandalised over false 5g coronavirus claims covid19 and the 5g conspiracy theory: social network analysis of twitter data 5g-ppp white paper on ehealth vertical sector statement on essential principles and practices for covid-19 contact tracing applications this work is partly supported by the european union in response 5g (grant no: 789658) and the academy of finland in 6genesis (grant no. 318927) key: cord-313384-v4g6dq6p authors: dönmez, nergis feride kaplan; atalan, abdulkadir; dönmez, cem çağrı title: desirability optimization models to create the global healthcare competitiveness index date: 2020-06-24 journal: arab j sci eng doi: 10.1007/s13369-020-04718-w sha: doc_id: 313384 cord_uid: v4g6dq6p the aim of this research is to enhance desirability optimization models to create a global healthcare competitiveness index (ghci) covering 53 countries with gross domestic product per capita (gdp pc) of over $10,000. the ghci is defined as an index that reveals the progress and quality of the healthcare systems in countries providing their patients with easier access opportunities to healthcare services within the scope of this work. methods of statistical analysis have been adopted together with optimization models and techniques in this research. the optimum and feasible values of the factors considered influential on objective functions have been determined as the basis of healthcare expenditure (he) and ghci in those relevant countries. those released optimum outcomes are displayed between 0.64 and 0.66 in terms of desirability value. the ghci values of those aforementioned countries range from 0 to 6. the computed average of the ghci values of those countries is estimated as 2.4758. finally, ghci values of 53 countries have been calculated to set the current basis of desirability optimization models. these findings will be deemed as the basic essence of those prospective theories to be established for the future researches to constitute a new index to measure the competitiveness of healthcare systems in various countries all over the world. the perspective toward the importance of the healthcare has already changed considerably in time. globally, healthcare is accepted as the second largest sector after manufacturing businesses in terms of economy. this situation has triggered the development and growth of the healthcare sector [1] . a competitive atmosphere is created for patients to receive faster and easier health services by means of healthcare institutions. accordingly, as the level of welfare of people increases, they demand higher quality of healthcare services from hospitals. all of these are particularly inspiring investors to promote quality assurance in healthcare systems of countries [2] . it is desirable for people to have high patient satisfaction by receiving high-quality services conveniently at healthcare institutions. especially, in european countries, people travel to other cities or countries because of poorquality healthcare services in the city where the patients are located. with the emergence of such a situation, many researches have been conducted to provide an easy, fast, and inexpensive healthcare service for patients [3, 4] . factors that enable patients to have an access to healthcare have been taken into consideration in such studies, but these studies have been performed for local situations rather than general conditions. in this study, a general view is presented considering the factors that form the infrastructure of the health systems of countries. a study measuring health system performance covering 191 countries was conducted by the world health organization (who) in 2000. five main factors defined as health, health inequality, responsiveness-level, responsiveness-distribution, and fair-financing were determined, and regression equations were formed in this study. the correlation between these factors and health system performance was emphasized. these factors were limited to [0, 1] , and a weighted value was given for each factor. thus, the overall efficiency calculation was made in all who member countries, and their health systems were listed. however, this study does not include any factors regarding the economic data and health infrastructures of countries. we would like to emphasize that it would not be appropriate to make a comparison between the study conducted by who and our study. because of the fact that the parameters discussed were different and that approximately 18 years had elapsed, there was no consistent comparison. many methods have been developed in terms of both engineering and management to solve health problems. especially, management approaches have been widely applied in the field of healthcare [5] [6] [7] . addressing managerial implications for the provision of medical devices [8] , increasing the types of services, providing improved management information systems [9] , employing skilled managers in their fields, patient case management, health quality assurance systems, and so on are important on behalf of the managers in determining the applicable strategies by taking into consideration in the field of healthcare management. thus, the effects of healthcare problems are finally concluded with implications by the research conducted by healthcare managers [10] . however, since healthcare problems are very specific issues or unique problems, such as avoiding vital harm to patients, insufficient resources, poor healthcare services, and medication error, researchers have adopted algorithms and optimization models in order to solve these issues [11] . therefore, optimization techniques are indispensable methods of management, engineering, and business applications. the purpose of using optimization, also named as operation research (or), is to provide maximum benefits (such as revenue and production) and minimize loss (such as costs, expenditure, defects, and waiting time). optimization applications vary widely according to the areas where they are used, such as energy, automotive, manufacturing, transportation, and logistic. optimization techniques have been exploited to solve problems in healthcare systems, which are among the most trend topics of recent years [12] . commonly, optimization models have been developed to optimize the schedule of resources of the healthcare systems. in addition, optimization models have been established for the management of healthcare materials for logistics [13] , for emergency services, to reduce waiting time for patients and to reduce expenditure or cost of treatment on healthcare facilities [14] . however, these methods have been used limitedly in the field of healthcare. the reason for this is that work or patient flows have a stochastic structure rather than a deterministic structure in the healthcare systems. stochastic constructions are usually explained by nonlinear equations, which means the analysis of mathematical modeling is both difficult and long-lasting in parabolic situations. statistical analysis is an alternative method for solving healthcare problems [2] . in particular, statistical methods have been used to make predictions for management of the healthcare system in the future based on past data and experience. especially, regression analysis was most widely used among statistical methods by researchers [15] . for this reason, regression analyses are considered as a good forecasting tool for the future. nevertheless, this tool is not sufficient to use solutions alone in healthcare area, because of the fact that the statistical analysis obtained provides only information about what the current system will achieve in the future, not the future goals of these systems. consequently, statistical analysis was used together with optimization technique in this study. in addition to statistical analysis, calculation of ghci values belonging to countries was provided by using desirability optimization technique. formulations were obtained by considering the lower and upper limits of the factors' values considered on the basis of this method. besides, it was possible to clearly show the traces of the factors on which they affect the response that was the objective function of the optimization model with the developed methodology. the problem statement which is an optimization model with the help of statistical analysis was developed to create ghci to measure the structural and economic status of healthcare of considered countries in this research. while the economic development of the countries has been measured with the global competitiveness index (gci) studies so far, in this study, we wanted to examine the development levels of the healthcare systems of the countries by creating a ghci [16] . up till now, the quality of healthcare has only been determined on the basis of patient satisfaction [17] . this criterion was measured according to questionnaire surveys, so the numerical data and analysis were disregarded in the studies [18] . patient satisfaction and employee performance were measured using questionnaire or verbal interview method to determine the quality of healthcare [19] . however, it is obvious that the results of such methods are weak in terms of accuracy or not enough to reflect the real problems of healthcare. for this reason, different methods have to be used to obtain the quantitative and tangible results. through this research, the results of the analysis with the numerical data by quality tools have led to touchable solutions for quality of the healthcare and allowed the detection of the future problems [20] . we believe that this study will be a good source for future studies in terms of the measuring method of the healthcare quality. also, this study will have significance in theory as it promotes a new index to measure the competitiveness of healthcare system across different countries. this study has come to fruition in four parts. in the first section, the studies in the literature have been discussed. the methodology of the study was considered in the second section. the factors affecting the healthcare systems were determined, and methodologies of the study were constructed on this part. the statistical, optimum, and feasible results were obtained with the developed method for ghci, and the ghci values belonging to the countries were calculated and ranked in the third section of the study. in the last section, conclusion about the study has been provided. the method used in the study consists of two parts as statistical phase and optimization phase. ghci values of the countries considered were calculated by developing nonlinear optimization models based on statistical optimization technique. as shown by the flowchart in fig. 1 , there are eight key steps as definition of inputs as decision variables, historical data collection, obtaining descriptive statistical information about the collected data and removing decision variables that are not statistically significant, determining the limits of decision variables, the decision variables and objective functions, creating the optimization models, and succeeding the optimum results for decision variables and objective functions in order to create ghci of the countries considered. in the statistical analysis stage, the statistical significance of the factors was analyzed to define the decision variables and the limits of these variables in the statistical analysis stage. optimization models containing decision variables that have an impact on the objective functions were developed, and optimum values of decision variables and objective functions were obtained in the optimization stage. finally, after calculating ghci optimization values not included in the flowchart, an index was created to list the healthcare systems of the countries considered in this study. the resources of the healthcare system of the countries were calculated by the world bank database as the number of beds, doctors, and nurses and midwives per 1000 persons. however, for the analysis of these data to be consistent, the total number of these sources was calculated as below: where x ij is defined as a decision variable and i denotes the resources of healthcare of the countries and j represents the names of the countries. in this equation, i only symbolizes the number of beds, doctors, and nurses and midwives per (1) x ij = total x ij 1000 1000 persons, but since there are more than one factor in the study, i notation representing the factors was used in general terms. likewise, j notation expresses generally the names of the countries considered in the study rather than writing them separately. a total − x ij refers to the total number of factors i for beds, doctors, and nurses and midwives in country j. the factors affecting healthcare systems were evaluated in two parts that were defined as structural and economical. the factors come from the resources that build the substructure of the healthcare system in the first part. the most important assessment for measuring the performance of a country's healthcare system is the relationship between resources and outcomes [21] . some of these factors are doctors, assistant doctors, nurses, officers, patient rooms, beds, triage rooms, laboratories fulfillments of clinical requirements, general behavior of doctors, registration and administrative procedures, infrastructure and amenities, professional performance of doctors, and facilities at reception and outpatient department area [17] . these resources must be supplied and managed properly in a healthcare system. nevertheless, deficiencies in the management of these resources are affecting the quality of healthcare in the negative direction [22] . generally believed, physicians, nurses, and beds construct the infrastructure of the healthcare systems [23] . thus, the numbers of physicians, nurses, and beds [24] that were used in this study were the most employed parameters in the researches [25] . we evaluated the effects of each resource on the different levels on of the outcomes and analyzed healthcare resources individually. the life expectancy [26] factor discussed was also considered among the structural factors in this study. especially, this factor may be more effective in state and private healthcare systems. as a result of the previous studies, there was a strong connection between hes and life expectancy [21] . the main reason for this deal was that people with high levels of prosperity are increasing their hes because people want to live longer. in this case, states or private enterprises need to increase their hes. in terms of economy, there are many factors that are influential in the healthcare system level headedly. there are two economic factors that are gross domestic product (gdp) and gross domestic product per capita (gdp pc) of the countries considered to be influential on the healthcare systems. countries with gdp pc of ten thousand dollars or more were regarded in this study. moreover, in the studies carried out in terms of the relation between healthcare and income level, a positive correlation appears to exist between the income per capita and life expectancy [27] . hes were considered as responses or dependent factors/ variables influenced by the independent factors. most of studies covered at most six and few independent factors in the calculation of index scores. generally, scientists suggested that the four independent variables, such as the number of physicians, nurses, beds, and healthcare expenditure per capita, were effective and reliable on the healthcare systems of countries. he data of countries [28] were calculated by the percentages of countries dependent on gdp [29] . a statistical analysis of how these factors affect he has been shown as the result. hes of countries were considered as response variables. it was seen that hes in economically developed countries are higher than those in developing countries. as a result of the statistical optimization analysis, the six important factors of which were gross domestic product, gross domestic product per capita, life expectancy, the number of beds, the number of nurses and midwives, and the number of physicians considered were more influential on hes as revealed in this study. optimization models were developed with the help of mathematical equations of the developed desirability functions. developed mathematical models are provided to minimize the amount of hes besides of maximization of ghci with objective function. the desirability analysis and optimization techniques have been merged to create the main methodology of this study. the desirability equations obtained as a result of statistical analysis and the ghci values belonging to the countries were calculated to construct the optimization models. contemplating types of factors among the countries with index i and j all notations are presented in table 1 . in the optimization model developed when decision variables are created for each country or each factor, there were 318 decision variables generated in total. likewise, a total of 319 constraints were created by considering the lower and upper limits of each factor, in addition to contemplating the nonnegative constraint in the optimization model. the method of desirability has been developed to obtain the best results for multiple reactions or factors acting as a process. (this method is widely used for multi-objective optimization models.) it produces the best response values of the factors to minimize, maximize, or reach the target value of the specifications. while statistical analysis gives mostly linear regression equations, the equilibrium found due to the weighted factor values in the desirability technique has a nonlinear characteristic. before constructing the optimization models, it is necessary to consider the function of desirability according to the results to be obtained as a result of statistical analysis. the factors affecting the response function directly influence the desirability function [30] . in short, it is desirable that the factors affecting the main response values are at the target values which are measured by the value of desirability. the best result is gained as this value goes from zero to one. the complete desirability function includes the upper and lower bound values of the factors that have an effect on the responses. ghci was created separately for each factor. ghci formula was obtained by geometric mean of these factors. however, the values of ghci and he are converted into the following formula in order to get a meaningful and accurate result. thus, the value of ghci and he was placed between 0 and 1. where d * denotes the geometric mean of the desirability indexes of the factors. d 1 , d 2 , d 3 , … , d n take a value between 0 and 1. if it is the worst and undesirable value. n indicates the number of factors and since there are six factors in this study, n = 6 is written. there were six different factors in this research, and the expansion of these factors on the desirability formulas as objective functions for the optimization models was shown as below: where l 1 , l 2, l 3 , … , l 6 and l 1 , l 2, l 3 , … , l 6 are the lower and upper specification limit of the responses, the power w 1 , w 2, w 3 , … , w 6 correspond to the weighted factor, and it is the parameter that determines the shape of d 1 , d 2 , d 3 , … , d n . . c is a multiplier that was used to have the result obtained have normal values in the equations. to find n factors' values, the value of each response value is expressed as y 1 , y 2, y 3 , … , y 6 . the following developed equations have been used as objective functions with the constraints to determine the competitiveness indexes of a country's healthcare systems. in this part, as a result of statistical analysis, finding the best solution and the results obtained in optimization models have been discussed. furthermore, calculating the ghci values of the countries considered, the advancement levels of the health systems of these countries have been ranked. this section provides general information about the collected data for statistical analysis and shows the accuracy of the analysis. the precision of the factors with the effects was measured on the response's variables. decision variables named as independent factors were abbreviated as gross domestic product, gdp; gross domestic product per capita, gdp pc; life expectancy, le; the number of beds, b ; the number of nurses and midwives, nw; and the number of physicians, md. the statistical analysis of factors and healthcare expenditure for factor i the country of j in the year y ∀ y ∈ � response variables are illustrated in table 2 . the results of statistical analysis showed that the accuracy of the collected values had high values of r 2 . the accuracy of the statistical analysis of this study was estimated as 99.68% of the r 2 value and 99.63% of the adjusted r 2 value. the effects of the determined factors on the ghci were examined based on hes. the importance of a factor on the response depends on the p-value of the factor as a result of the statistical analysis. contribution ratios were calculated as percentage of contributions to the total sequential sum of squares of each source in table 2 . higher percentages of contributions rates indicated that it calculated more variation on the responses. the most important factor was found as gdp pc by country in the statistical analysis. (p-value of gdp pc was computed as zero.) gdp, the numbers of nurses, physicians, and beds were found to be more impressive factors on hes and ghci. however, these results indicated that ghci were not influenced by the hes of countries. thus, this factor was excluded in the application optimization model to calculate optimum values of remained factors, which was defined as an objective function. note that the effects of factors considered for ghci were measured as non-interactively. optimization mathematical models for optimizing both the factors and the objective functions (or response) were developed to compute the optimal and feasible values. these values show the necessary data to compete for a country in the field of healthcare. considering the factors analyzed, the calculated values were higher than the mean of the data of 53 countries. as a result of the statistical analysis revealed, sixth of the important factors discussed was more effective on hes and ghci in this study. figure 1 shows the variation in the optimum and feasible results obtained for ghci and hes according to d*. the optimum point was located between 0.52 and 0.68 of d* (with the creation of graphic for feasible solutions, the d value was calculated as 0.72 maximum and the minimum value as 0.40, respectively) shown in fig. 2 . the optimal point located to be within the feasible region, but two different objective functions (for different directions: max-min) ensure that the solution was nonlinear. the objective functions and the factors constituting the constraints that have optimum and feasible values are demonstrated in table 3 to determine the individual effects of the factors that could affect the response and *statistically significant (p-value < 0.01), **at the margin of statistical provisionally significance (p-value < 0.1) contribution: displays the percentage that each source contributes to the total variation in the response ci: confidence interval is an interval estimation type for the actual values of an unknown population parameter calculated from the statistics of the observed data p-value: the p-value is a probability that measures the evidence against the null hypothesis the values that each factor takes outside of optimum values were seen to affect the objective function either in the positive or negative direction. according to table 4 , as gdp pc values of the factors increase, the value of the objective functions defined ghci and he decrease. this had a negative effect on ghci, while it had a positive effect on hes. the bidirectional tendency in the objective functions leaded to the transformation of the developed optimization models into nonlinear mathematical equations. on the reverse side, the values of gdp increase among the factors, the value of the objective function assigned ghci increases and the value of the objective function assigned he decreases. we could mention gdp and gdp pc are bidirectional tendency for the healthcare system of the country with the increase in life expectancy values as well as bidirectional effects on the healthcare system of a country. in terms of the resources, healthcare had different situations for ghci and hes. the values of the rest of these sources, except nw, affect the objective functions to a certain extent. however, the numerical increase in these two resources reaching a certain number did not affect the value of ghci and hes as well. in addition, md and b factors did not have any effect on the desirability function defined d*. the effect of the factors affecting the healthcare system on ghci and he is shown in fig. 3 . the calculation of the optimum values for each factor was completed by considering the d* value. areas formed constitute the feasible zone for the objective functions in fig. 3a -l. the most important point to be considered in these figures was that the factors that were effective in the healthcare system have the maximum values for the ghci value (local maximum), forcing it to be at a minimum level (local minimum) for he. there are two different behaviors in order to get the optimum values of the factors. the factors desire to get the maximum value for ghci and want to get the minimum values for he based on constructed optimization models. therefore, d* values were calculated from different ranges for each figure. in addition, although he and ghci were defined as two independent objective functions, ghci was affected by hes. our findings inferred that he should continue to improve ghci so that ghci can become a much better forecaster of the quality of healthcare. the optimization model with statistical analysis has been developed to demonstrate the competitiveness of the healthcare systems of the countries covered in this study. country selected rankings were made by calculating the ghci scores of the countries with this study on healthcare. we aimed to show that a country with a high ghci score has a quality and competitive health system. thus, the healthcare systems with high ghci score will have the ability to offer a better service to the patients. the ghci scores of the countries ranged from 0 to 6. the average of the ghci values of the countries was calculated 2.4758. when the ghci scores were examined, it was found that the highest value was in the usa (5.7490) and the lowest value was in qatar (0.4301) (see table 5 ). the ghci score of many countries was below the optimum ghci value. only seven out of 53 countries were above the optimum ghci value. the ghci score of 19 countries was above the average ghci score. the rest of these countries need to improve their ghci scores immediately. the results of this study partially coincide with the results obtained in several studies. the increase in hes is caused by various factors, such as aging of the population, medical technology, and developments in living standards. in the context of the investigations, as people's quality of life and their willingness to live increases, hes increase. in terms of the data, it is seen that hes are high in economically developed countries further than developing countries [21] . in terms of the healthcare, policies of governments are examined, and it is desirable to reduce the he which is a burden on the country's economy. according to observations, it was determined that the values of hes fluctuated from country to country. the levels of hes were mainly calculated as high in usa, japan, germany, france, and uk, while hes were estimated low particularly in cyprus, lithuania, estonia, latvia, and croatia. comparing different countries defined locational, we can advocate that in the european region, where there was a high number of developed countries, and the level of hes was the highest compared to the other location. as a remarkable point, there are large differences in hes among european countries. for instance, in the level of he in germany, france was higher than the level of he in finland and greece. obviously, we can conclude that there was an imbalance in the hes of countries close to each other. the most noteworthy factor in countries with above average ghci value is the amount of gdp in these countries. it should be noted that the fact that the amount of the hes is high in a country does not mean that it has a quality healthcare system. indeed, the patient satisfaction surveys support this outcome in most of these countries. according to the government policies in these countries, it is a common idea to reduce hes. the countries with high hes (such as uk, canada, japan, italy, germany, france, and usa) healthcare systems are needed to be examined in detail. it is inevitable that countries with social and nonsocial healthcare systems will have an impact on hes. when we look at health services in a comparative way, the high proportion of elderly people from the scandinavian countries has become a major challenge in the delivery of healthcare. likewise, the length of waiting times due to the density of the elderly has become unacceptable for england. in this regard, there is the pressure of providing the service to be provided in the health sector to its citizens before overseas people. despite the revised health system in the usa, there are sectoral problems due to the increasing cost of health expenditures. although most of the citizens in the country have complementary supplementary insurance, they cannot get a comprehensive service. in this regard, in order to receive full-scale healthcare, out of the country are mostly exported from the usa. however, the usa is still at the top of the list of competitive health sectors because it maintains its position as the most advanced country in terms of private healthcare management and innovation. this study has also its limitations. for example, the indices such as the number of private and public hospitals of a country were not able to be considered in this study because of lack of information about them. however, our independent variable as the number of beds or exam rooms instead of the number of hospitals was considered in the optimization models. another limitation was about the data being relatively short-term. we recommend that we use decision variables to predict long-term global healthcare index five years and beyond. we have taken a small step to compare several factors that may impact the ghci. we found that two economic dimensions can be better indicators than he even though he is also a good predicting variable for high-quality healthcare service. we encourage for further refinement of the ghci by including healthcare resources (types of hospitals, technicians, technology, etc.) and the components of healthcare (governments as a rule/law maker, pharmaceutics sector, healthcare insurance companies, etc.) so that it can become a more reliable index. thus, it may be able to better predict future ghci. since there are limited studies on this subject (being the first study on this subject), this study is very important for future studies in order to calculate the index of healthcare systems for cities or countries. healthcare dates back ancient times depending on the development of the world and humanity. applications of the politics in terms of health system have been determined, and adapting it to the changing world scheme, the process of drawing up different approaches for each term have been considered in a methodology in relation to the approaches of national and international elements affecting that period. the rise in the cost and expenditure of healthcare during this process is now determined by many variables, on the one hand, with the use of high technology to provide healthcare, the existence of expensive treatment methods in the form of supply, on the other hand, rise in income, improvements in the living standards, demographic changes, etc., in the form of demand. the existence of these items necessitates the application of changes. when health sector is considered socioeconomically, the main reason why developments in health sector should be mostly financed: a) by public sector and b) by private sector is regarded as a problem to be dealt with is related to finance and carrying out this organization. as the corona virus (covid19) , which emerged in chine and spread around the world, bringing out global health and economic problems along with, the importance of public sector has once been shown to be highly important in the field of healthcare. as a consequence, it is necessary that public should carry out an effective and leading service regarding the evaluation of health system and healthcare because the most important reason of this situation is the conversion of a health system, which has a social structure, to a nonsocial structure. the basis of this study was to develop optimization models to use the healthcare economics of the countries more efficiently. in these models, the constraints were derived from the factors that affect the healthcare economics besides healthcare systems. thus, the optimum and feasible values of the factors as well as the ghci and he data were calculated in this study. according to the results of the study, we proved that allocating too much he budgets (that can be regarded as waste) does not guarantee to have a high-quality healthcare system in a country. index of healthcare competitiveness shows how good the quality service is in the healthcare field of countries. this index determines the ease or difficulty of receiving services of patients from hospitals or other health institutions. taking the results obtained into consideration in this paper, the competitiveness of a country's healthcare system will only be possible if it carries optimum or feasible values. we have concluded that countries under these values have low quality of healthcare systems. on the centrality of strategic human resource management for healthcare quality results and competitive advantage accessibility testing of european health-related websites temporal pacing of outcomes for improving patient flow: design science research in a national health service hospital an integrated methodology for evaluating patient service quality modelling and analysis of inventory management systems in healthcare: a review and reflections quality management in healthcare organizations: empirical evidence from the baldrige data smart healthcare: an approach for ubiquitous healthcare management using iot the clash of managerial and professional logics in public procurement: implications for innovation in the health-care sector scheduleit-open-source preventive actions management plataform in healthcare information systems hospital adaptation to risk-bearing: managerial implications of changes in purchaser-provider contracting introducing competition in healthcare services: the role of private care and increased patient mobility event-driven ecg sensor in healthcare devices for data transfer optimization service philosophies for hospital admission planning modeling cost and expenditure for healthcare designing simulation experiments with controllable and uncontrollable factors for applications in healthcare is global competitive index a good standard to measure economic growth? a suggestion for improvement factors affecting patient satisfaction: an exploratory study for quality management in the health-care sector associations between waiting times, service times, and patient satisfaction in an endocrinology outpatient department: a time study and questionnaire survey assessing the value of healthcare interventions using multi-criteria decision analysis: a review of the literature design and application of new quality improvement model: kano lean six sigma for software maintenance project. arab the relationship between life expectancy at birth and health expenditures estimated by a crosscountry and time-series analysis how can we achieve and maintain high-quality performance of health workers in low-resource settings? safe design of healthcare facilities oecd: oecd data health care resources impact of health system inputs on health outcome: a multilevel longitudinal analysis of botswana national antiretroviral program world population review: life expectancy by country 2017 human development in poor countries: on the role of private incomes and public services oecd: oecd data health expenditure (percent of gdp) world bank: world health organization global health expenditure database. health expenditure, total (% of gdp) optimization of correlated multiple quality characteristics using desirability function conflict of interest the authors declare that they have no conflict of interest. key: cord-333509-dnuakd6h authors: chan, hui yun title: hospitals’ liabilities in times of pandemic: recalibrating the legal obligation to provide personal protective equipment to healthcare workers date: 2020-10-17 journal: liverp law rev doi: 10.1007/s10991-020-09270-z sha: doc_id: 333509 cord_uid: dnuakd6h the covid-19 pandemic has precipitated the global race for essential personal protective equipment in delivering critical patient care. this has created a dearth of personal protective equipment availability in some countries, which posed particular harm to frontline healthcare workers’ health and safety, with undesirable consequences to public health. substantial discussions have been devoted to the imperative of providing adequate personal protective equipment to frontline healthcare workers. the specific legal obligations of hospitals towards healthcare workers in the pandemic context have so far escaped important scrutiny. this paper endeavours to examine this overlooked aspect in the light of legal actions brought by frontline healthcare workers against their employers arising from a shortage of personal protective equipment. by analysing the potential legal liabilities of hospitals, the paper sheds light on the interlinked attributes and factors in understanding hospitals’ obligations towards healthcare workers and how such duty can be justifiably recalibrated in times of pandemic. the onslaught of covid-19 has led to a worldwide race for personal protective equipment ("ppe") ranging from protective goggles, gloves, full face shields, fluid repellent gowns, aprons, surgical masks, and medical equipment such as ventilators and respiratory machines. 1 the british medical association has repeatedly issued urgent pleas to the uk government for the timely supply of ppe for frontline healthcare staff in delivering patient care. 2 frontline healthcare workers without ppe continue to face severe infection risks posed by ppe shortage constitutes a pressure point for healthcare systems, with strong correlations between its scarcity and high covid-19 infections and death among healthcare workers. 4 covid-19 has claimed more than 300 healthcare workers' lives, and infected more than 60,000 in the usa, 5 while ppe shortage and substandard ppe in spain have resulted in more than 31,000 healthcare workers becoming infected. 6 reports of heightened stress experienced by frontline staff are not new; either from the fear of being infected or in transmitting the infections to their families. 7 the shortage has prompted drastic reactions from some governments in downgrading ppe protection standard inconsistent with who advice, inevitably raising questions about harm to healthcare workers. 8 this measure in turn produced several adverse effects on care provision. it has created an exodus of critical healthcare staff due to their inability to continue working. clinical decisions were made to either delay care or minimise the risks of harm (while still working in high risk environments), underscoring rationing in action, and making difficult situations more taxing. although they are not compelled to continue treating patients, the inability to do so generated moral guilt as they see their colleagues on the frontline operating in hazardous conditions. recent developments have witnessed strong responses from the public and healthcare workers, ranging from pursuing legal actions against the government or their employers (hospitals) for breaching their obligations of care towards employees to calling for a full public inquiry into pandemic management, including the status of the ppe stockpile. 9 specific claims by healthcare workers include the legality of guidance on reusing ppe and permitting patients to be treated without ppe in contravention of their right to protection of health and safety at work. 10 this development is not only confined to the uk, as doctors in spain have launched legal actions against the health authorities for breach of duty in ppe procurement failure. 11 considerable coverage continued to be given to issues concerning allocation of scarce resources, the clinical and moral dilemma to treat, and the urgent need to have protective gears for frontline staff. 12 the pressing legal considerations regarding employer's failures in procuring sufficient resources for pandemic purposes remain under-explored. this paper examines how the pandemic affects the obligations of hospitals as employers towards their frontline healthcare staff in fulfilling their responsibilities during pandemic, and the impetus on re-evaluating existing and future legal obligations. it considers the extent to which hospitals have breached their obligations in failing to take appropriate measures to safeguard the health and safety of their employees and to prevent them from being exposed to avoidable risks. while convincing justifications are available regarding the difficult roles of hospitals during pandemic, significantly persuasive arguments can be made for hospitals' liability in breaching their duty to ensure the safety of healthcare workers. these claims will be considered in determining the extent to which such liability can be recalibrated in times of pandemic. while the analyses are drawn from the uk context, the substantive importance is equally relevant as the battle for critical medical supplies is felt across the world. an employer's duty is personal and non-delegable. the employer's duty is one of reasonable care and skill, to provide a safe place and system of work, with adequate plant and equipment, including competent employees and resources, according to the industry and environment in which they operate. 13 such obligations extend to maintaining the equipment and ensuring that they are of sufficient quantity, necessitating regular inspections and monitoring. 14 providing a safe system of work signals a gamut of considerations; ranging from ensuring proper working systems, arrangements and instructions, identifying the purpose of the work, specific tasks and scope to assess risks and install precautionary measures for the employees' health and safety. a system of work thus encompasses an assessment of the adequacy for the "whole course of the job or it may have to be modified or improved to meet circumstances which arise." 15 the consequence of this duty is that the system ought to be reasonably safe, and not perfectly safe, through assessing the inevitable dangers associated with the work, guided by industry norms. 16 these norms often evolve through time and employers must be aware of such developments in updating their 12 emanuel et al. (2020) , ranney et al. (2020) . 13 wilsons & clyde coal company v english [1938] ac 57, lunney et al. (2017, p 560 safety standards to reflect current knowledge based on best scientific evidence. 17 consequently, though it can be suggested that the science of covid-19 is still developing, the lack of knowledge regarding its effect may not automatically preclude employers from being liable. doctors, surgeons and nurses employed in the service of hospitals are treated as employees under the law and hence they are owed a duty of care. 18 the common law duty of care identified above thus obliges hospitals to provide competent staff, adequate material and a safe, proper system and effective supervision. the extent to which employers ought to provide for ppe invites considerations such as the risk, likelihood, magnitude and consequences of the injury, and the availability and costs of providing such protective equipment. 19 in hospitals, the provision of adequate plant and equipment signifies ppe such as gloves, masks, full length gowns, shields and goggles. hospital working zones have become "contagion hubs" with streams of patients (symptomatic and asymptomatic) receiving care and treatment from healthcare workers. it is reasonably anticipated that healthcare workers are continuously exposed to significant infection risks from treating these patients. the provision of ppe is directly relevant to the work for which healthcare workers are employed to do, and which are normally and reasonably expected to be provided with, consistent with who guidelines for treatment of infectious diseases. the omission to provide ppe to frontline staff unavoidably attracts questions of hospitals' negligence. in determining whether the employers are negligent in failing to remedy the lack of ppe, reference is made to a number of important factors under the common law and statutory instruments. factors that illuminate the liability of the parties, such as the nature of the work, its inherent risks, the (im)possibility of establishing precautionary measures in preventing or reducing the likelihood of risks materialising, the extent to which such measures commensurate with the means and ends, are examined. risk assessments, particularly whether the risks are amplified by the failure to provide in an otherwise acceptable risk in employment, common practices, and resources similarly influence the determination of duty. statutory duties under the health and safety act, regulations on ppe 1992, the relevant guidance issued by the department of health and social care and public health england to healthcare workers are relevant considerations. risk assessment is an important feature in determining the likelihood of injury and whether a breach has occurred in a system of work. it sets the level of reasonableness of precautionary measures against the health and safety risks employees may encounter in the course of their employment. 20 the firemen assuming risks associated with not having a jack fitted in the truck, thus precluding their employers from liability. it has been questioned whether this approach has unjustly discriminated claimants from emergency services that continue to assume risks for the greater good 22 but is otherwise uncompensated for the injuries sustained. there is considerable force in this reasoning that applies to frontline healthcare workers. they face prolonged risks on a daily basis, which includes periods of emergency and hours with clinical rotations between high and low infection risks zones in hospitals. their purpose is to save lives, but without ppe they are putting the lives of patients at risk. the likelihood of injury is real and the gravity of the consequences is magnified. while there are risks inherent in patient treatment, infectious diseases attract extra hazardous elements into the work. the seriousness of harm caused to healthcare workers is not considered small. infected healthcare workers would be off sick, unable to treat, and face the possibility of death. the risks of infection are higher without ppe compared to those with basic ppe. standard public health practices require healthcare workers to don appropriate ppe. this in turn invites questions on cost and practicability 23 in addressing the risks that persist in daily clinical encounters. although frontline healthcare work is not intrinsically dangerous compared to crane workers in the building industry, the cumulative risks arising from covid-19, and other preventable factors could potentially render such employment dangerous. healthcare workers combating infectious diseases accept the associated risks that are intrinsic to the work; that does not mean that they have voluntarily assumed all those risks which could be prevented or reduced with the exercise of reasonable care by the hospitals. 24 the example of healthcare staff at weston hospital in england who tested positive after contact with infected patients only goes to demonstrate the severity of the situation. 25 if we accept that covid-19 is hazardous, then it justifies the protection from the risks of infection through ppe provision. ppe constitutes the first line of protection against infections, as they need to be in close proximity to patients. ppe thus can reduce the chances of infection and in some cases prevent further infections among healthcare workers. such risks clearly outweighed the cost of providing ppe, and the omission to provide is obvious. while the likelihood of the majority of the healthcare workers to succumb to the virus is small owing to the age and health demography, the consequences of such infection materialising are grave if they were infected. courts usually take into account established practices in assessing whether the defendants have breached their standard of care given the circumstances prevailing at the time. 26 it can be reasonably said that ppe is a common practice; logical and of common sense in treatment of infectious diseases. hospitals should act in 22 accordance with such approved, common practice of ensuring adequate ppe supply. the most practical preventive measure, which is providing ppe is not onerous, compared to the risks of injury to healthcare workers. while cases have shown that employers have not breached their duty in failing to provide protective screens or suitable emergency vehicles for the employees at wartime, 27 ultimately, balancing these risks against the measures to remove the risk requires a consideration of the end to be achieved. 28 the end to be achieved in the pandemic context is the dual outcomes of protecting public health and maintaining the health and safety of healthcare workers in the course of their employment. statutory instruments have given the duty of care a stronger emphasis. the personal protective equipment at work regulations 1992 ("ppe regulations") under the health and safety at work act 1974 clearly set out the types of legal responsibilities that employers should follow. ppe under the regulations means "all equip-ment…intended to be worn or held by a person at work and which protects the person against one or more risks to that person's health or safety, and any addition or accessory designed to meet that objective." 29 consequently, ppe in the hospital context is broad enough to include all equipment that protect healthcare workers from infectious particles arising from aerosol generating procedures, ventilators, respirators or testing facilities with high concentrations of droplets or airborne diseases. regulation 4(3) provides the litmus test for the suitability of such ppe. ppe are considered "suitable" relative to the risks involved for the purpose of carrying out the work, the conditions and duration of exposure, the state of health of the wearer, the workstation's characteristics, and practicable in controlling the risks. ppe has to be hygienic and for the sole use of the wearer, thus the guidance to reuse them may raise questions, unless they are addressed by having adequate measures that ensure the hygiene is not compromised where reuse is needed. 30 such ppe should also be maintained and replaced. 31 the exposure to covid-19 infections is directly workrelated, and employers have the means to protect and implement control measures to reduce the chances of risks materialising. these circumstances directly oblige hospitals to ensure that ppe stockpiles are sufficient so that they are readily at hand when they are needed by the healthcare workers. the difficulty arises when there is a disparity between the actual supply and provision of ppe, and meeting compliance with the legal requirements. recent public health england 32 (phe) guidance has emerged in response to the pandemic in advising hospitals on establishing a safe system of work through 27 yorkshire traction company limited v walter searby [2003] ewca civ 1856; in daborn v bath tramways ltd [1946] 2 all e.r. 333, at 336, the driver of ambulance with left-hand drive was found not negligent when, in wartime, she turned to the right without giving a signal. 28 watt v hertfordshire [1954] 2 all e.r. 368. 29 regulation 2(1)(a). 30 for example the phe guidance noted that some ppe may be reused, subject to effective cleaning system. 31 regulations 5 and 7. 32 phe is tasked with national oversight and leadership on public health issues, and in this capacity support nhs, manage national public health service and support the public health workforce development, see also herring (2016, p 54). organisational means, ranging from suitable work processes, engineering controls, environment, and provision and use of both work equipment and ppe (single sessional use of particular ppe, reusable ppe) and decontamination procedures. 33 the guidance recognised the employers' legal obligation to protect workers from health and safety risks in controlling and limiting infection transmissions, including assessing risks associated with patient influx, and reduced staff numbers due to illness. this aspect corresponds with regulation 5 in assessing the risks of injury and the purpose and adequacy of such gears where available. however, developing phe guidance, in addressing ppe shortage highlighted "the compromise needed to optimise the supply of ppe in times of extreme shortage… protect stock levels from unnecessary use and support staff to use the right equipment." 34 such modifications mean that ppe are used throughout the session unchanged between patients, "as long as it is safe to do so", which differ from the who guidance. other modifications, such as lower grade face masks reflect a standard which is lower than the who recommendation. while reusing gloves should be avoided, some ppe such as face masks, gowns and eye protection are only liable to be changed when they are visibly contaminated or damaged. the implication is that such ppe would have lost the protective function, putting the healthcare workers at risk under the guise of protection. the direct correlation between staff engagement and patient experience demonstrates the close association between the quality of care patients received and the provision of treatment by healthcare workers. 35 the nhs, a government-funded healthcare service under which hospitals in the uk operate sets the standards for service provision and professionalism. in essence, it commits to provide high quality, safe and effective care, and recognises that a valued and supported workforce will translate to quality patient care. 36 the nhs constitution, which outlines the basic principles and values of the nhs governing the relationships between healthcare workers, patients and the public generally, illuminates particular rights under employment laws, and nhs pledges to their staff, with the overarching priority of delivering patient centred care. patients have the right to be treated professionally by qualified healthcare workers as part of a safe system of work in a clean and secure 34 public health england, department of health and social care and nhs england (2020). 35 guidance: handbook to the nhs constitution for england (2020). 36 nhs, the nhs constitution for england (2020). 33 several guidance were published advising hospitals of rapid changes to ppe use and disposal: guidance: introduction and organisational preparedness 21 may 2020 https ://www.gov.uk/gover nment /publi catio ns/wuhan -novel -coron aviru s-infec tion-preve ntion -and-contr ol/intro ducti on-and-organ isati onal-prepa redne ss; guidance: covid-19 personal protective equipment (ppe) 20 may 2020 https ://www.gov.uk/ gover nment /publi catio ns/wuhan -novel -coron aviru s-infec tion-preve ntion -and-contr ol/covid -19-perso nalprote ctive -equip ment-ppe produced jointly by department of health and social care (dhsc), public health wales (phw), public health agency (pha) northern ireland, health protection scotland (hps), public health england and nhs england. environment, signalling the necessity of an appropriately equipped and maintained environment. the cyclical nature of patient care and duty to staff is clearly reflected, with explicit recognition that staff should be provided with the resources and support to deliver quality patient care and for healthcare workers to identify and eliminate risks to patients. the failure to provide ppe for healthcare workers has significant relevance and broader implications to patient care. healthcare workers with substandard or without ppe are exposed to infection risks, rendering them susceptible to absence from work for at least 14 days, resulting in workforce depletion. this is especially critical for healthcare workers functioning in high risk zones. healthcare workers operating in other units would be asked to support the continuity of care for covid-19 patients, thus creating a void in patient care in less critical areas. frontline healthcare workers face immense pressure treating patients under crisis. while there is an expected level of stress 37 that corresponds with the nature of the work in providing care, transferring workers from other specialty units to assist their frontline colleagues may prove exacting, given that their training and competency for the job can vary. the rerouted human resources meant that patients in other units are inadvertently neglected due to reduced staff. another serious, adverse outcome is the risks of transmitting the infection to patients where healthcare workers are unaware that they have been infected; particularly in asymptomatic situations. ppe greatly reduce the risks of infection in the first place, for both the health and safety of the healthcare workers and patients. the strong correlation between the augmented risks of infection and ppe shortage creates a system where patients are harmed. the commitment to deliver quality patient care and a good working environment has, unfortunately, become questionable in this environment. while the nhs constitution provides for avenues of complaints to line managers, the bureaucracy meant that staff will continue to face infection risks unless they refuse to treat patients. 38 prior insights from previous pandemic and the lack of remedial measures to address the weaknesses identified in the healthcare system during national pandemic simulation exercises may raise valid concerns regarding errors of judgement that resulted in the inability to provide ppe in a timely manner. public authorities hold and exercise discretionary powers within the constraints of complex decisions, social utility and organisational objectives. however, are we setting a standard too high for the nhs managers in procuring ppe, given the prevailing circumstances? are there any exceptions to this duty in times of pandemic, where it can be reasonably anticipated that healthcare systems may become inundated, resulting in the necessity of working within a less than optimal environment? the following sections consider arguments 37 see walker v northumberland cc [1995] 1 all er 737. 38 bowcott (2020) . and counterarguments limiting hospitals' legal obligations towards healthcare workers. the characteristics of covid-19 are essential in understanding the severity of the pandemic, its impact on the healthcare systems, and why particular focus on the legal obligations of hospitals towards healthcare staff becomes significant now and in the future. the morphology of covid-19 has garnered international attention, with scientists investigating its biochemical components for preventive, containment and vaccine trials purposes. it was first reported in wuhan, hubei province of china on 31 december 2019, with origins traced to the 1960s as common viruses that infect humans, particularly in respiratory functions. 39 the transmission methods and survival on various surfaces have been the subject of intense scrutiny with findings that the virus can be detected on surgical masks for up to seven days. hospital working areas such as intensive care units, self-isolation wards, doorknobs and keyboards are found to carry high concentration of viruses. viruses were present in the body for more than a week prior to visible symptoms with the highest virus load found in the early stages of infection, suggesting that asymptomatic individuals could be more infectious than symptomatic ones as sources of population transmissions. 40 these findings are crucially linked to the recommendations for use, reuse and disposal of ppe and its effect on healthcare workers who were infected. around 10% of infections in england recorded between april and june 2020 were found in health and social care workers resulting from their direct interactions with patients in hospitals. 41 spain, italy, china and the usa have reported between 10% and 20% of infection cases from healthcare workers while treating infectious patients. this underscored the detrimental effects of ppe shortage on healthcare workers. 42 the lack of ppe has cast the spotlight on augmented risks to healthcare workers. such risks of harm are widely acknowledged. 43 healthcare workers experienced psychological and moral distress, frustrations and anxiety in carrying out treatment decisions, fear of risking their health, and infecting their families and patients. they are similarly exposed to emotional harms from being prevented to voice their concerns on health and safety, or compelled to provide care under unsafe circumstances. the british medical association has repeatedly supported the position that healthcare workers should not continue working with substandard ppe or without basic ppe that could prevent them from avoidable harm. 44 however, this has not allayed the harmful consequences to healthcare workers. 40 ibid. 41 wilson et al. (2020) . 42 who (2020). 43 british medical association (2020), carrington (2020), smyth (2016) . 44 british medical association (n 43, p 7). 39 european centre for disease prevention and control (2020). the force of the covid-19 exigency poses an arguably persuasive factor in limiting employers' liability. while covid-19 is frequently hailed as unprecedented, the nature of influenza pandemic is not completely unknown. history has revealed examples of pandemic that occurred across centuries with various degrees of severity. 45 once the who declared covid-19 as a pandemic, ppe became global focal points. countries rushed to secure additional ppe, with demands far exceeding supply within an asymmetrical circulation of medical resources. although the challenge of scarce resources is a common predicament affecting hospitals, simulation exercises (e.g.: public health england 2016) undertaken in some developed countries provide ample opportunities for advance preparatory measures. the experiences of frontline healthcare workers from other countries several months before the pandemic reached the uk would have constituted sufficient notice of the gravity of the situation. hospitals have grown in complexity through centuries. the extent to which institutional structures, devolved administrations and resourcing constraints provide justifications for their omission needs to be determined within their role as public authorities. the nhs structure is represented by a complex matrix of quasi-government, private entity with specific powers and responsibilities, thus affecting their liability to healthcare workers as employees, moving beyond the simplicity of hospitaldoctor employment relationship. it has been said that "to describe the structure of the nhs is not an easy task…partly because it is a labyrinthine and partly because the nhs has been and still is undergoing enormous structural changes with bodies being created, merged and destroyed at an astonishing rate." 46 the nhs is funded from taxes, with allocations approved by parliament, and expenditures controlled by clinical commissioning groups. 47 nhs managers work in a complex environment, from purely administrative to larger roles of system management and leadership with accountability to frontline healthcare workers, the department of health, private providers, and subject to public scrutiny. 48 nhs managers are expected to balance several competing rights, among others the public health, healthcare workers' rights and organisational constraints. 49 the creation of internal market supported by the health and social care act 2012 has been critiqued as one of the structural problems permeating nhs 50 which produced a considerably weakened responsive capability during pandemics. continuous public sector changes, marketisation strategies 45 walsh (2020) . 46 and funding cuts have led to the government's reliance on private firms to provide services during public health emergencies. 51 suggestions that phe decisions were politically influenced have led to allegations that ppe guidelines were not necessarily led by public health science, as seen in the case of lowering ppe standards due to shortage, contrary to who recommendations. hospitals performed their functions within the wider framework of organisational complexities, decision-making hierarchies and limitations, and political willpower. they often have statutory responsibilities involving difficult and sensitive judgements to make. 52 they also inadvertently suffer from particular authority or financial barriers, which puts them in unenviable positions when faced with claims of negligence in equipping employees with ppe. the discretionary powers available for public authorities, other remedial options and consequences for public service delivery influence how standards are determined. 53 a finding of liability may result in obstructions with the exercise of discretionary powers guided by particular reasoning within the system for purposes of efficient and necessary governmental machinery. 54 the structural determinants illuminate the systemic failures that plagued these entities. as christian witting accurately observed 55 : "in some cases, decisions made at a high political level inevitably entail difficulty in meeting service targets or in under-servicing, and must be expected to result in failures in care. the failures in care that result are systemic in nature. their acceptability is politically pre-determined and courts might have little authority to redress them." resource availability within public authorities remains a pressure point among competing sets of considerations. 56 it indicates the dilemma of meeting social needs for the effective functioning of society within a finite environment of resources. public authorities traverse the boundaries of public and private law in judicial applications of the law of negligence, human rights and statutory powers. 57 this is reflected in the nhs context, which represents one of the most politically charged and publicly contentious issues of all times. 58 daborn demonstrated that in cases of national emergency, the lack of available transportation resources, the inherent limitations of the ambulance and the need for continuity in emergency services precluded the defendant from further duties. while not a complete defence, public service liability is 51 closely connected to resource constraints, weighing against the finding of liability. 59 cases have shown that although public body should not be treated any differently from commercial employers, financial constraints and rigidity in decision-making are relevant factors. 60 this signifies the balance between resource availability and cost and practicability of preventing workplace injury. the issue of how far the duty should go when it comes to omissions to provide ppe in a pandemic context is unresolved. given the public health crisis precipitated by the pandemic, it is likely that hospitals would be 'forgiven' for their failure in fulfilling their legal obligations on the basis of emergency and their constraints as public authorities. however, hospitals are the linchpin in delivering frontline healthcare services and maintaining public health in an infectious disease setting. it is argued that hospitals should depart from an approach that expose healthcare workers to infection risks, harm public health and is inconsistent with the core nhs patient centred care principle. the provision of ppe is fundamental to healthcare workers in carrying out their work. ppe protect healthcare workers, and in turn enable them to deliver crucial care especially in times of pandemic. it is not an infallible method, but without these ppe they are most likely to suffer from injury and harm from the risks of infection. the failure to provide ppe to healthcare workers is a failure to deliver care to patients at critical points. the size, capacity and resources available to hospitals are influential considerations; nevertheless, they are not determinative to the extent of justifying the omission to provide ppe. a comparison can be drawn to ppe provision during normal times and in times of emergency. in normal times, the impact, while it may be felt, may not be acute for patient delivery care because the limit has not been breached. however, in emergency times, the impact of the failure to provide ppe to healthcare workers is severe. the daborn and watt v hertfordshire cases had established the importance of the end to be achieved in saving lives, consequently such emphasis can be inferred as recalibrating the obligations of essential services and balancing the rigidity and prescribed exclusion of liability. when the objectives are to save lives and ensure the continuity of vital healthcare delivery, it would appear contradictory to omit the provision of ppe that directly enable the treatment and care of patients. the lives of frontline healthcare workers and patients justified the provision of ppe. these arguments deviate from the standard argument of resource constraints, but they offer a strong reasoning why they should not be precluded. imposing the duty to provide ppe is therefore central in ensuring healthcare workers are protected from the risks of infection and to realise the aim of delivering patient-centred care to the public. thus, this duty should be adjusted to the extent of meeting the requirement of basic provision of ppe and ensure the continuity of such ppe supply in spite of the pandemic. this argument may seem contentious because there are persuasive cases that will preclude the finding of liability in a situation where resources are scarce and that individuals are expected to endure the crisis. however, hospitals need to demonstrate that they have proper mechanisms in place to address shortages in prolonged crisis instead of relying on arguments of budgetary limitations and hierarchy in decision-making. these points need to be identified at each step along the way to determine if the standard of care has been reasonably met. while cases involving public authorities often lend weight to the exclusion of liabilities; they can be distinguished from the current situation in several ways. first, the shortage in question is remedied by the availability of vehicles for the continuity of services, despite not the usual vehicle (e.g.: left-hand drive in daborn). the covid-19 situation represents a context where healthcare workers have exhausted these basic supplies and faced the consequences of no ppe for the remaining clinical encounters. second, covid-19 is not a singular incident but an event that is urgent in nature and continues on a daily basis. the severity of the harm meant that without any protection they face a high likelihood of being infected. the lowered standards of ppe use and recommendation for reusing ppe are attempts at remedying the complete shortage. the argument is that some protection is better than no protection. although hospitals are attempting to meet their obligations; ppe which are visibly damaged would cause harm under the guise of protection. the persistent lack of funding to hospitals has contributed to an environment where ppe shortage is tolerated and accepted as standard (though not reasonable) practice. ppe guidelines that decrease the health and safety standard exemplifies resource consideration. it is difficult to comprehend, even at the basic level, for employers not to provide essential ppe for protection against known risks within standard public health measures. covid-19 is an infectious disease, and the reasonable response is to provide ppe that eliminate or reduce the risks from exposure to such infections. while the purpose of the work is such that infections are incidental to the nature of the employment, ppe is an indispensable and cost-effective measure in minimising such risks. in spite of the difficulty in functioning within a resourcelimited environment, ppe is not purely best practice, but fundamental medical practice. an implication flowing from these considerations is recalibrating the mutual obligations between hospitals and their employees, underpinned by effective healthcare delivery consistent with the nhs constitution. a blanket approach to the finding of liability may be unsuitable, as not all hospitals are similarly equipped, though it remains incumbent on hospitals to fulfil their basic obligations without jeopardising the safety of healthcare workers. parallels can be drawn to the established standards and practices relating to ppe for employees working with hazardous materials. ppe can be modified but only to the extent where they are capable of providing full protection to healthcare workers, and not lower than the recommended standards. ppe availability inculcates a sense of assurance that frontline healthcare workers are valued and appreciated, both by the public and their employers, and for the workers, the confidence in carrying out their roles in treating and caring for infectious patients. system deficiency may be influential in determinations of liability, but it does not always prevail over what is reasonably expected from hospitals. hospitals have the moral duty to take care where their actions will affect those who might be affected by the failure to provide adequate and safe ppe: staff and patients. such duty falls within the remit of nhs managers. as covid-19 progresses, hospitals ought to have foreseen the impact of ppe on healthcare workers and patients; given the length of the pandemic, rather than a singular emergency. not all finding of liability will automatically result in floodgates, trivial claims or become burdensome for public authorities. 61 rather, it reflects the social and public expectations of what is fair and reasonable. the legal claims filed by healthcare workers for ppe shortage reflect societal expectations of what ought to be done in ensuring healthcare workers are provided with sufficient ppe. departing from this standard would have stretched the limits of acceptable assumption of risks. the public, while accepting that covid-19 is an unprecedented health threat to the population, will not be kind in their assessment of the measures to contain the pandemic, particularly in response to the dearth of vital medical resources in times of crisis. it becomes imperative to recognise their vulnerabilities and to keep healthcare workers safe. systemic failures may well be compelling, but it is unsatisfactory to then say, there is nothing hospitals could do. reports have continuously demonstrated the correlation between the lack of ppe and higher risks of infection for healthcare workers compared to the public. 62 this naturally translates to poor patient care as they become sick. there is clear neglect in ensuring stockpiles of ppe in meeting the basic requirement of ensuring workers' health and safety. the lack of clear direction and protocols in management and leadership has contributed to the failure of establishing a safe system of work. what would a reasonable healthcare provider do? it is to provide adequate ppe when it is needed and to have processes in place to supplement the stockpile. the saving of lives is a continuous emergency, reflected by the number and severity of patients healthcare workers treat daily. the discretionary power should be exercised towards ensuring resources are allocated towards meeting the obligations of hospitals during pandemic, in preparing sufficient ppe for healthcare workers. for example, the procurement team of the nhs trust is responsible for purchasing supplies and equipment for the hospital, where specific purchasing rules and budgetary limits apply. this translates to broader governmental responsibilities within the decision-making authority which subsequently influenced the overall level of pandemic preparedness. the long-term deficiency in preparedness for a potential infectious diseases outbreak, and the failure to remedy ppe availability through systematic and appropriate procurement arrangements for continuous supply have contributed towards hospitals' inability to replenish severely dwindled ppe stocks in a timely manner. these cumulative factors have resulted in the breaching of ppe limits to the detriment of healthcare workers. the hesitance towards advance preparedness is remarkable, given the window period available to the uk with precedents from china and neighbouring european countries. 63 hospitals, especially the well-resourced ones, with the hindsight of previous experiences in treating patients under the deluge of pandemic could have 61 phelps v london borough of hillingdon [2001] 2 a.c. 619. 62 parshley (2020) . 63 hunter (2020), mahase (2020a, b, c, d). foreseen the need to install precautionary measures to safeguard the continuity of essential supplies and safe functioning of workplace for healthcare workers. adopting such preparatory measures would have enabled a safer response strategy for critical patient care in anticipation of increased burden on the frontline staff, adjusted according to the size and scope of the hospitals' operations and resources. the next section offers practical recommendations in pre-empting ppe shortage. the failure of hospitals in providing healthcare workers with ppe has resulted in concerted and self-help measures in procuring ppe. the most common preparation is stockpiling essential ppe. this comes as a benefit of hindsight; nonetheless valuable in preparation for second or third waves of infections, and as crucial planning for future pandemics. for example, prior to the onset of infected cases in new york, some hospitals have acquired millions worth of ppe as early as february 2020 on the basis that "you can never have enough." 64 this foresight paid off, enabling healthcare workers to continue working while protected. an appreciation for improved procurement procedures in place, such as the role of supply chains in ppe procurement is integral in successful pandemic preparation. the public-private procurement chain has ensured that new zealand has sufficient ppe for the healthcare workers and the population, with additional weekly supplies from local manufacturers. 65 the shortage in the uk remains acute. reports have emerged that care home workers were requested to continue caring for infectious patients without ppe in the event of extreme shortage. 66 local councils are responsible for delivering healthcare services (e.g.: care homes and community mental health services) which falls outside the nhs supply chain scope. this means that they are most likely to lack ppe in times of national emergency. jurisdictional divisions have, unfortunately hampered the effective cooperation for public health to the detriment of frontline healthcare workers and the public. 67 the systemic impediments in the nhs organisational structures might be difficult to overcome immediately, but the awareness of how ppe delivery is hampered by these institutional barriers can pave the way for alternative routes to remedy the situation. supply chain management and logistical issues are beyond the remit of employees personally, and those in charge of organisational operations should be responsible in fulfilling the obligations in ensuring that ppe are in stock and at hand when they are needed. this means having additional supplies for emergency purposes 64 ornstein (2020) . 65 covid 19 coronavirus: tonnes of ppe now in auckland warehouse 9 apr, 2020 https ://www.nzher ald. co.nz/nz/news/artic le.cfm?c_id=1&objec tid=12323 807. 66 taylor (2020) . 67 see further laurie and hunter (2009). while procurement for additional ppe is in progress to ensure continuity in supply for healthcare workers. consequently, measures include revisiting internal procedures in assessing the individual levels of preparedness in hospitals, and preparing alternative plans in redirecting patients to hospitals with more capability to deal with infectious patients if the scale and capacity of the local hospitals do not permit the proper treatment and availability of care to the patients without risking staff safety. it is equally valuable to treat the pandemic as akin to disaster response with mass casualties as it enables the operation of protocols and processes for such emergencies occurring for a substantial period of time. nhs managers must be aware of such developments, encompassing clinical and administrative appreciations of the effect global supply chain has on essential ppe procurement in planning and reducing the gap between stock depletion and arrivals. this entails building good, working relationships with relevant suppliers and producers. as resources are finite, having operational plans in advance at the institutional level would alleviate the burden of dealing with these issues during emergency when there are absolutely no ppe available. infrastructural planning, reorganisation and improvisation are essential to remedy the weaknesses that prevented hospitals from fulfilling their obligation in providing a safe system of work and adequate plant and equipment for the purpose of caring for patients. it is not advocated that there should be a perfect system but a functioning system at a fundamental level that ensures that employees' health and safety are not compromised in times of pandemic, and that risks are controlled within reasonable limits. longer term measures include instituting improved communication among hospitals within proximate areas in breaking the disease transmission chains locally and regionally. this approach will facilitate local capabilities in minimising the disease spread, especially in under-resourced and rural areas healthcare services. such regional networking approach has resulted in successful pandemic response among 15 hospitals in lombardy, italy in coping with patient surge. 68 the current decentralised decision-making approach in the nhs and the lack of effective communication policies in disaster management have led to critical resourcing issues. 69 processes and procedures that allow a centralised, consistent response mechanism in national emergency are essential in ameliorating some of the difficulties in pandemic response and management. for example, an emergency "clearinghouse" that acts as a centre is helpful to identify areas with high needs for ppe so that immediate actions can be taken to distribute ppe to these critical areas. 70 increasing local production capacity and supply in times of crisis are central in ensuring uninterrupted supply from local sources and less reliance on external producers during ppe scarcity. spain, for example has aimed to produce millions of masks and other essential ppe on a monthly basis to meet the needs of healthcare workers. 71 when the shortage was first reported, the local and national level 68 cavallo et al. (2020) . 69 hunter (n 63). 70 livingston et al. (2020) . 71 sappal (2020). communities in the uk were very supportive towards the healthcare workers in creating homemade ppe and supplying them to healthcare workers. although this is admirable, these supplies may not meet the adequate level of protection to ensure that infection risks are minimised. one way of overcoming the obstacle is to create a streamlined effort between local governments, charitable organisations and local volunteer groups to ensure they meet the safety requirements. this approach would help local and independent manufacturers to achieve local production capacity for the benefit of the communities within a shorter amount of time, and less dependent on outsourced procurement agencies or importation. it is also a stop-gap measure while awaiting incoming ppe supplies from centralised distribution centres. this move is advantageous to the local communities, as local hospitals can continue to treat patients without being forced to turn them away due to ppe shortage. reusing ppe is an option to ease the pressures of ppe shortage. however, the direction to reuse ppe can only be safely implemented where there are protocols for cleaning, disinfecting and storing reusable ppe and limited to ppe that are capable of being reused safely. such essential protocols must include appropriate laundry capacity, whether in hospitals or outsourced to commercial entities. 72 other options include repurposing suitable equipment into ppe that are safe to use for eye and face shields, such as gas masks or sports eye protectors. employees should not be put in an already vulnerable position without the minimum support and infrastructure to carry out their work. the pressing problem of insufficient ppe represents the tip of the iceberg. it reveals a fragile structure in the healthcare system, with the implications of covid-19 felt long after it has come and gone. the level of provision of care for the population in times of pandemic is closely connected to the health workers' risks and safety. the analyses bring to light the importance of implementing sustainable measures for population health. more innovative ideas are needed for producing and replenishing important resources to pre-empt the domino effect arising from a lack of resources in times of pandemic. 73 hospitals are obliged to be more forthcoming in providing clarity with regards to the supply of resources, and to accommodate the possible reluctance of healthcare workers in working in unsafe circumstances. frontline workers who are being prevented from airing their concerns on the severe lack of adequate ppe is detrimental to their functions in providing care. it could not be said to have met the aims of patient safety when staff are not equipped, valued, empowered or supported in carrying out their work. this paper has highlighted how the pandemic has affected the legal obligations of hospitals to healthcare workers in the provision of ppe. hospitals as employers have obligations towards healthcare workers, which include providing a safe 72 livingston, desai, and berkwits (n 70). 73 ibid; cavallo, donoho and forman (n 68). working environment and adequate equipment. the nature and extent of their duty are affected by their role as public authorities and in times of emergency. hospitals usually do not incur liability on the basis that they have service provisions that are influenced by resource constraints, limits in decision-making authority and bureaucracy. daborn and watt v hertfordshire exemplify the types of constraints public authorities face in providing social services, which weighed against the finding of liability. there are persuasive arguments from both perspectives in determining the extent of liability hospitals may incur in their failure to provide ppe in a timely manner. yet legal actions against governments and hospitals have opened up the possibility to reconsider the scope of liability, and the fulfilment of the expected standard under pandemic circumstances. the analyses show nhs managers would be in breach of duty for provision of ppe on the basis that the purpose of their activity is relevant in determining if an employer has breached a duty of care to an employee. while the negligence may be arguably excused during crises, the failure to meet the basic resourcing needs of frontline healthcare workers has breached the minimum standard and ethical imperatives in protecting them from life-threatening harm while they continue to treat an increased influx of patients. additionally, it has highlighted broader issues that plagued ppe procurement readiness preceding the pandemic. the analyses have indicated the extent to which the meeting of legal obligations in a pandemic can be undermined by external, underlying pressures arising from austerity policies introduced throughout the years, and an increasingly privatisation-oriented procurement practice, consequently weakening the public sector capacity in competently meeting public health threats. it is hard to dismiss the consistent pleas from frontline healthcare workers. such pleas strengthened the recognition of obligations to provide ppe. maintaining public health and safety in times of pandemic is of utmost importance; however the public can only be properly cared for where healthcare workers are able to continue working in a relatively safe environment in the midst of a pandemic. the fundamental need for ppe and the health and safety of healthcare workers must be prioritised. while this paper has gestured towards the obligations in providing ppe, the analyses have shed light on the inextricable implications of sound governance in meeting health priorities during a pandemic. it has canvassed a broader profile of underlying issues and proposed recommendations, emphasising the need for cohesive measures to address ppe shortage and alleviate the risks to frontline healthcare workers. the state may not be able to salvage the deaths and distress caused to frontline healthcare workers, but it can act more substantively to protect them and to restore public trust that the healthcare system would not collapse in times of pandemic. it has been argued here that hospitals ought to maintain their obligations to provide ppe to healthcare workers, because a failure to adequately protect them is also a failure to protect public health. supporting the health care workforce during the covid-19 global epidemic lacking beds, masks and doctors, europe's health services struggle to cope with the coronavirus apr bma. 2020. covid-19: ppe for doctors doctor couple challenge uk government on ppe risks to bame staff 24 covid-19-ethical issues. a guidance note uk strategy to address pandemic threat 'not properly implemented. the guardian hospital capacity and operations in the coronavirus disease 2019 (covid-19) pandemic-planning for the nth patient bereaved relatives call for immediate inquiry into covid-19 crisis doctors step up plea for adequate protection against coronavirus covid 19 coronavirus. 2020. tonnes of ppe now in auckland warehouse cecilia faulty batch of face masks prompts the isolation of more than a thousand spanish healthcare staff 21 doctors to file legal challenge to ppe guidance 21 fair allocation of scarce medical resources in the time of covid-19 european centre for disease prevention and control: an agency of the european union guidance: considerations for acute personal protective equipment (ppe) shortages 3 s-infec tion-preve ntion -and-contr ol/covid -19-perso nalprote ctive -equip ment-ppe. department of health and social care (dhsc) guidance: handbook to the nhs constitution for england bma demands urgent ppe solution after 50 italian doctors die from covid-19 oxford: oup. high proportion of healthcare workers with covid-19 in italy is a stark warning to the world: protecting nurses and their colleagues must be the number one priority 20 covid-19 and the stiff upper lip-the pandemic response in the united kingdom covid-19: doctors still at "considerable risk" from lack of ppe, bma warns mapping, assessing and improving legal preparedness for pandemic flu in the united kingdom how a decade of privatisation and cuts exposed england to coronavirus 1 sourcing personal protective equipment during the covid-19 pandemic text and materials, 6th ed global stocks of protective gear are depleted, with demand at "100 times" normal level, who warns covid-19: 90% of cases will hit nhs over nine week period, chief medical officer warns covid-19: hoarding and misuse of protective gear is jeopardising the response, who warns novel coronavirus: australian gps raise concerns about shortage of face masks protecting health care workers against covid-19-and being prepared for future pandemics covid-19: doctors' leaders warn that staff could quit and may die over lack of protective equipment nhs. 2020. the nhs constitution for england how america's hospitals survived the first wave of the coronavirus remember the n95 mask shortage? it's still a problem exercise cygnus report tier one command post exercise pandemic influenza press release: new personal protective equipment (ppe) guidance for nhs teams 2 up to 40% of staff tested at hospital after covid-19 patient contact had virus critical supply shortages the need for ventilators and personal protective equipment during the covid-19 pandemic spanish government faces legal action over lack of ppe for medics 1 spain gears up to manufacture 10 million masks a month as well as other vital covid-19 equipment stone, will, carrie feibel. 2020. covid-19 has killed close to 300 u.s. health care workers, new data from cdc shows care home staff could be asked to work without ppe under council plan 3 the changing role of managers in the nhs king's fund department of health with powers derived from national health service act 1977 national health service and community care act 1990 implementing the code of conduct for nhs managers here's how some of the countries worst hit by coronavirus are dealing with shortages of protective equipment for healthcare workers covid-19: the history of pandemics shortage of personal protective equipment endangering health workers worldwide who and countries are engaged in massive preparedness activities covid-19 news: uk could eliminate coronavirus entirely, say scientists 6 national health service rationing: implications for the standard of care in negligence street on torts key: cord-338730-49ai51ah authors: baashar, yahia; alhussian, hitham; patel, ahmed; alkawsi, gamal; alzahrani, ahmed ibrahim; alfarraj, osama; hayder, gasim title: customer relationship management systems (crms) in the healthcare environment: a systematic literature review date: 2020-08-31 journal: computer standards & interfaces doi: 10.1016/j.csi.2020.103442 sha: doc_id: 338730 cord_uid: 49ai51ah abstract customer relationship management (crm) is an innovative technology that seeks to improve customer satisfaction, loyalty, and profitability by acquiring, developing, and maintaining effective customer relationships and interactions with stakeholders. numerous researches on crm have made significant progress in several areas such as telecommunications, banking, and manufacturing, but research specific to the healthcare environment is very limited. this systematic review aims to categorise, summarise, synthesise, and appraise the research on crm in the healthcare environment, considering the absence of coherent and comprehensive scholarship of disparate data on crm. various databases were used to conduct a comprehensive search of studies that examine crm in the healthcare environment (including hospitals, clinics, medical centres, and nursing homes). analysis and evaluation of 19 carefully selected studies revealed three main research categories: (i) social crm ‘ecrm’; (ii) implementing crms; and (iii) adopting crms; with positive outcomes for crm both in terms of patients relationship/communication with hospital, satisfaction, medical treatment/outcomes and empowerment and hospitals medical operation, productivity, cost, performance, efficiency and service quality. this is the first systematic review to comprehensively synthesise and summarise empirical evidence from disparate crm research data (quantitative, qualitative, and mixed) in the healthcare environment. our results revealed that substantial gaps exist in the knowledge of using crm in the healthcare environment. future research should focus on exploring: (i) other potential factors, such as patient characteristics, culture (of both the patient and hospital), knowledge management, trust, security, and privacy for implementing and adopting crms and (ii) other crm categories, such as mobile crm (mcrm) and data mining crm. healthcare organisations face substantial pressure to maintain high quality medical care while simultaneously increasing safety and reduce costs [1, 2] . issues such as the growing number of chronic illnesses and the ageing population; higher patient demand and expectations; and the lack of qualified medical professionals, have complicated healthcare organisations' ability to fulfil their missions [3, 4] . health information technology (hit, also known as e-health or medical informatics [5] ), is viewed as a significant tool to achieve cost savings, efficiency, quality, and safety [6] [7] [8] . the benefits of hit include: improved medical services and workflows, providing decisionmaking support and clinical information for medical professionals, expanding the quality, safety, and effectiveness of patient care, preventing medical errors; and reducing expenses, admissions, and paperwork [9] [10] [11] [12] [13] [14] [15] [16] . many studies suggest that the effectiveness of implementing hit will determine the success and survival of the healthcare industry. consumer e-health, patient engagement, and patient-centric care also play significant roles in delivering high quality medical services and meeting patient needs [17] . many studies have found that the more patients are involved in their own health, the better outcomes in terms of quality, cost, and performance [18] [19] [20] . healthcare providers now see the patient more clearly as the end consumer of medical services; thus, as in any kind of business, the concept of patient satisfaction and loyalty has become healthcare organisations' foremost concern [2] . this paper is organised as follows, section 2 illustrates our review methodology which describes the search strategy, keywords used, selection process, critical appraisal, data collection and analysis. section 3 presents and summarises the key findings of the selected studies. the main findings with response to the research questions, strength and limitations of the review as well as future work suggestions are discussed in section 4, and section 5 concludes the paper. for this study, a systematic review was conducted of disparate (quantitative, qualitative, and mixed) evidence of crm [59, 60] , following the criteria of preferred reporting items for systematic reviews and meta-analysis (prisma) [61, 62] . these include the following steps: (1) eligibility criteria; (2) information sources; (3) search terms; (4) study selection; (5) data collection process and synthesis; and (6) critical appraisal. studies were eligible for inclusion if they were: presenting an empirical and conceptual evidence; directly relevant to crm in healthcare settings (hospitals, clinics and medical centres); papers that are conducted in developing countries; published from 2000 to present; and published in peer-reviewed journals. the main reason for selecting studies that were conducted in developing countries is because health technologies play an important role in the effectiveness of patient care and treatment, yet access to such technologies remain a big challenge for communities with limited recourses. we excluded studies if they were: not written in english; traditional reviews, thesis and conference proceedings; papers that focused on other healthcare domains such as insurance and pharmaceuticals; and papers that were not available in full text. our methodical procedure used various strategies to obtain as many relevant studies as possible from a diverse evidence base [63, 64] . in the first step, we searched the database of abstracts of reviews of effects (dare) and the cochrane database of systematic reviews (cdsr) to verify if there were any existing or ongoing systematic reviews similar to our subject. secondly, we conducted an organised, systematic and comprehensive wide-ranging search of six online databases: web of science, sciencedirect, scopus, springerlink, ieee xplore, and the association for computing machinery (acm) digital library. we also examined four group publishers of academic journals (emerald insight, wiley online library, taylor & francis online, and sage digital library) and two search engines (pubmed and google scholar). to identify relevant studies, we then performed a library search of six medical informatics and health management journals: (1) the journal of medical internet research; (2) the journal of the american medical informatics association (jamia); (3) plos (public library of science) one; (4) bmj open; (5) the international journal of medical informatics; (6) bmc medical informatics and decision making. we also contacted two experts in the field to find additional or unpublished relevant studies. finally, we checked reference lists of all eligible studies using google scholar to discover hidden additional studies. it should be noted that each online database has its own search engine features. hence, the search string had to be modified and adapted for each online database. to do so, our search was recorded in a separate text that includes the following details: source category, source name, search method and date of search for each online database. this can be seen in table 1 . the search process is very crucial; therefore, the keywords were optimised. in the first stage, we obtained a set of keywords and terms from the acquired studies and matched them with our research aims and questions. secondly, we established alternative characteristics and synonyms. the defined keywords were tested in different databases and lastly, we optimised them. table 2 summarises the final list of keywords used in the search. next, logical operators were connected with different sets of keywords and designed as follows: (crm or crm system or crm technology) or (prm or prm system or prm technology) and (healthcare industry or healthcare sector or hospital or healthcare providers or medical centre or medical service) and (developing countries). the study selection process attempts to analyse, evaluate and identify relevant articles based on the goals of our systematic review. this process was independently performed by three co-authors (h.a., a.p. and g.a.) of this study. table 3 explains each stage that has been executed in the study selection process. in the first stage (s1), records are identified through different information sources (online database, academic journal and reference list). once all records are obtained, we applied the first filter in the second stage (s2), to which records are excluded based on duplicates. we used endnote x9 to remove duplicates and manage all records. once all duplicates are removed, records are screened based on "title, abstract and keywords", during this third stage (s3), any studies that did not meet the eligibility criteria were excluded. also, during this stage, we considered studies for a "full-text" screening, and arranged meetings between co-authors whenever there were doubts. such meetings have allowed co-authors to review and agree on studies that were within the scope and pertinent to this systematic review. the first meeting (s4), aimed to discuss the findings of the third stage and select the primary studies for the next stage (s5), where a "full-text" screening of all studies was performed. a second meeting, which was the last stage (s6) of the selection process, was carried out to discuss and agree on the final studies that are included in this systematic review. we used endnote x9 to collect basic publication data such as date, title, authors, publisher, doi, url, pages, volume, issues, keywords and abstract. in addition to endnote, one co-author (g.h.) of this study placed data from eligible studies into a data extraction spreadsheet using microsoft excel 2016, then two other co-authors (y.b. and a.p.) validated it independently. the data items extracted from each eligible study were: year of publication; author; brief description; type of evidence; participants; sample size (n); healthcare organisation type and size; country of origin, and outcomes. to synthesise the data as accurately and in an unbiased manner as possible, we performed a narrative synthesis review for effectiveness [65] of diverse study characteristics, which allowed us to categorise and identify three main crm research categories that were relevant to healthcare settings: (i) e-crm (web-based crm); (ii) implementing crms; and (iii) adopting crms. we also created a qualitative and quantitative evidential narrative summary [60, 63] for each crm research category. we contacted the original authors of the selected studies by e-mail to resolve any doubts or confirm an absence of information. in addition, any disagreements between co-authors of this study were settled through consensus. two co-authors (a.i.a and o.a.) of this study independently appraised the quality of selected studies to avoid misinterpretation and bias. we followed the criteria of quality assessment and assurance tools for undertaking a systematic review of disparate data developed by hawker et al. [66] . table 4 elaborates the checklist that is used to appraise each individual study. this checklist is based on nine assessment criteria with four rating scores defined as good, fair, poor and very poor respectively. a description of how these ratings were assigned and evaluated is described and illustrated in table 4 . our primary concern being to obtain sufficient knowledge and evidence of the nature of crm in the healthcare environment, and we performed sensitivity intervention analysis [67] to determine whether: (i) the inclusion of each study was based on its quality, and (ii) the exclusion of empirical data from conference proceedings would have any effects on our ultimate results. we resolved disagreements on critical appraisal of the selected studies through group discussion and with "chairperson" arbitration assistance given by the first author (y.b.) of this paper. firstly, we illustrate the results of our study screening and selection process according to prisma guidelines. secondly, we describe the trends and characteristics of the selected studies and present quantitative data (i.e. publication year and location, methods of data collection, table 2 list of keywords used in the search process. settings, participants and sample sizes). thirdly, we demonstrate the results of our critical appraisal of each study, and lastly, we summarise the crm research categories. all findings stated in this section are directly responding to our set of three research questions (rqs). in our initial search, we found 1642 studies (see fig. 1 ). we identified a total of 1682 studies for the review, including those found through manual searches of medical informatics and management journals (n = 17), and reference lists (n = 23). studies removed after duplicates (n = 693). applying the eligibility criteria, we excluded 891 studies by screening the title, the abstract and the keywords. finally, we excluded 79 based on the full text screening. hence, the final sample consisted of 19 studies. as shown in fig. 3 , most of the studies were conducted in taiwan and iran (n = 10, 53%), which indicates the advanced production of ict and medical informatics in those regions and therefore associated research efforts into their impact. of these, 21% (n = 4) were carried out in india and jordan. the rest took place in iraq, brunei, korea, malaysia and kuwait. among the selected studies, 68% (n = 13) had quantitative designs. the remaining studies used qualitative (n = 3, 16%) and mixedmethod approaches (n = 1, 5%), while two studies (11%) were based on conceptual modelling of crm (see fig. 4 ). the healthcare settings were mainly various kinds of hospitals (n = 11, 58%) such as private, public, regional, community and university hospitals (fig. 5 ). the rest of the studies were conducted in nursing homes (n = 2, 11%) and health centres (n = 2, 11%). four studies (21%) were conducted in multiple settings such clinics, homecare centres, and health promotion centres. among the targeted groups, 47% of the studies (n =8), have simultaneously recruited multiple stakeholders such as patients, patient families, medical staffs, crm experts, nurses, nursing professionals, nurse supervisors, his professionals, chief executive officers (ceos), or chief information technology officers (citos). as shown in fig. 6 , the remaining respondents were management (24%), physicians (6%), patients (6%), nurses (6%), and auxiliary medical staff (6%). majority of the studies have utilised a sample size between 200 and 399 (n = 5, 31%). only one study has used a sample size of more than 400. fig. 7 illustrates the variation of the sample sizes used in the selected studies. our critical appraisal of the selected studies (see table 5 ) found major weaknesses in four areas: (i) research methods and data, (ii) sampling, (iii) ethics and bias and (iv) implications and usefulness. in terms of research methods and data collection and analysis, studies gave little descriptions of the methods and approaches to gather and record data in a consistent manner (rated as fair and poor in 53% and 26% of the studies, respectively). regarding the sampling, some researches lacked details on the sampling techniques and strategies, the justification of the sample size and target groups, as well as the response rates (assessed as fair, poor, and not reported in 47%, 21%, and 5% of the studies, respectively). furthermore, the ethics and risk of bias was not clearly reported in 74% of the studies. we rated the implications and usefulness of the selected studies as poor and not reported in 47% of total studies. the results of this review remained reliable and consistent, even after we performed the sensitivity analysis to determine whether we included each study based on its quality, and whether excluding empirical data from conference proceedings had any effects on our results. our analysis of the selected studies revealed three main categories of crm research in the healthcare sector: (i) e-crm (web-based crm); (2) implementing crms; and (3) adopting crms. while precisely 58% of the selected studies (n = 11) focused on implementing crms, other research categories were less frequently investigated: social crm (n = 5, 26%), and adopting crm (n = 3, 16%). fig. 8 shows the representation of crm research categories. social crm or e-crm is a new concept that has emerged into the crm systems due to the incessant advancement of it and web services, as well as other advances in ict and data science techniques. the authors of [68] defined e-crm as a modern approach and a system that integrates both web 2.0 and the influence of online groups with conventional crm systems to build strong communication and relationships between the customers and the firms. in the healthcare environment, many studies have explored the phenomena of e-crm. as early as 2001, kohli et al. [69] explored the web-based crm system in a hospital through a physician profiling system (pps). results gathered after implementing pps showed that total charges were significantly reduced, which led to better care and patient's satisfaction. the authors of [70] proposed a social crm model to support patient empowerment through a web 2.0, namely crm 2.0. they surveyed 366 patients, patients' family members and medical staff from various hospitals and homecare centres to determine patients' expectations of ehealth services, and to verify the empowerment features proposed in the model. this study found that there was high demand for empowering patients through the web. the findings also revealed that more than 80% of targeted groups preferred to view health promotions, make appointments and payments online. while more than 75% preferred to go online to view their own medical records and discuss their health conditions on a social network. also, 73% of participations desired an table 3 stages of the study selection process. description participants s1 selection of studies identified through different information sources. h.a., a.p. and g.a. exclusion of studies based on duplicates. h.a., a.p. and g.a. exclusion of studies based on a "title, abstract and keywords" screening, against the eligibility criteria. all authors s4 consensus meeting. exclusion of studies based on a "full-text" screening. online consultation. the authors of [71] developed a framework for implementing e-crm, and surveyed 150 managing directors and branch managers from 50 clinics and hospitals (both public and private) to investigate the key factors of executing e-crm based on their importance and priorities. this study concluded that patient's involvement is the most important factor in implementing e-crm. an e-crm adoption framework was proposed by jalal et al. [72] to determine the crucial factors that influence the adoption of e-crm in hospitals. toe, diffusion of technology and institutional theories were utilised in the construction of the framework. this work found that technological factors such as complexity and relative advantage; organizational factors such as size and management support; and environmental factors such as regulatory and external pressure are very crucial for e-crm adoption. similar to this work, the authors of [73] proposed an e-crm implementation framework utilising technology-organization-environment (toe), diffusion of technology and information system (is) success theories and found that technological (compatibility, interactivity and privacy); organizational factors (management support, social media policy and leadership knowledge) and environmental factors (social trust and bandwagon pressure) are very critical for e-crm implementation. as early as 2005, cheng et al. [74] established a framework to *score criteria for qa = quality assessment the study also found that most nursing homes have yet to implement crm, and computerisation requires more effort. the authors of [77] argued that the crm framework proposed by cheng et al. [74] was inappropriate because their results were obtained from a value characteristic questionnaire. however, the two sub-dimensions of cm, 'interactive mechanism' and 'assessment of demand models', did not clearly map all the attributes defined in the survey. accordingly, similar to the work of [74] , gulliver et al. [77] adapted a value characteristic framework to support establishing crm in nursing homes. this study found the most three significant dimensions to be: the 'behaviour of service personnel', the 'design of care processes', and 'support from related units'. based on the findings, the authors claimed that approaches to executing crm in nursing homes would be inappropriate if only one solution was considered to fulfil all the attributes. accounting for each attribute would ensure consistency, relevancy, and provide an effective, focused plan. while allowing each individual characteristic to be linked to a specific crm solution type would support the practical implementation of crm, we believe the adapted framework could also assist hospitals, especially in terms of answering the following questions: (1) what are the most valuable elements of putting crm into practice? and (2) how can we link each feature to a crm solution type? the authors of [78] adopted the soft system dynamics methodology (ssdm) and used a case study on a physical examination centre to evaluate the steps of applying a crm model. ssdm integrates the qualities of both soft system methodology (ssm) and system dynamics (sd) that involves four phases with ten systematic steps. the results showed that the four stages and ten systematic steps allowed the authors to positively measure and evaluate the crm model. improved efficiency, as well as provided a better service for health organisation were outcomes of this process. the authors of [79] explored the key factors of realising crm systems, and proposed a model based on three attributes: (1) the organisation itself (resources, management, and employee factors); (2) applying crm (the crm system factor) and (3) the customer (the patient factor). the authors recommended and proposed the 'delone and mclean information systems (is) success model' to assess crm implementation. the authors of [80] proposed and adopted the 'delone and mclean is success model' for executing crm based on three traits: (1) the system (system quality, information quality, and sq); (2) the user (perceived usefulness and user satisfaction) and (3) performance (organisational and personal performance). they administered a survey to 243 crm system users from 13 health promotion centres to validate the aforementioned is model. the outcomes showed that (1) the crm model was feasible; (2) of system attributes, only 'information quality' and 'sq' had a significant influence and relationship with 'perceived usefulness' and 'user satisfaction' and (3) 'perceived usefulness' and 'user satisfaction' had a significant impact on 'personal performance' as well as an indirect effect on 'organisational performance'. the authors of [81] surveyed 615 staff members in 108 privately run and 30 hospital-based nursing homes to assess crm implementation. the author adapted the crm scale developed by sin et al. [82] , which involves four dimensions: (1) a key customer focus; (2) crm organisation; (3) technology-based crm and (4) km, along with 23 subdimensions. however, in this study, only 18 sub-dimensions were adapted to evaluate crm implementation. furthermore, the study found that the two types of nursing homes had different ways of building relationships with residents. hospital-based nursing homes leaned toward understanding patients' needs and delivering prompt medical service through the concept of 'knowledge learning'. private nursing homes focused on 'crm organisation' and 'technology-based crm' to foster personal connections with residents. another crm implementation model was introduced by zamani and tarokh [83] , this model consists of seven components; customer satisfaction, loyalty, trust, expectations, perceptions, perceived quality and architecture. a total of 303 patients were surveyed and found that all seven components were significant and have relationship with each other. also, the authors of [84] designed a crm implementation model based on hr factors such as employee satisfaction, organizational culture, communication management, empowerment, organizational commitment, organizational structure and change management. this work surveyed 215 managers of a university hospital. findings revealed that hrm plays a crucial role in the implementation of crms. however, the employee satisfaction factor had the highest influence on the implementation of crms. the authors of [85] surveyed 100 patients and crm users to analyse the factors that influence the implementation of crm based on software aspects. results showed that operational efficiency, centralization of data, management of existing customer and hospital image have a significant influence on the implementation of crms. the authors of [86] evaluated the effects of crms implementation on customer trust, loyalty, satisfaction and organisational productivity. they administered a survey to 268 crm nurses from various hospitals. results showed that customer satisfaction and diversification have the highest effects on crms implementation, while organisational productivity had the lowest impact. the authors of [87] investigated various impacts and benefits of implementing crms in hospitals. more than 550 of doctors, administrators and it staffs were surveyed and found that waiting time reduction, better doctor allocation, and patient satisfaction were the major implication of crm implementation in health care. to investigate the critical factors that influence the adoption of crm systems (crms), hung et al. [21] performed a 95-questionnaire study of information systems (is) executives at three levels of health organisations: medical centres, community hospitals and regional hospitals. the results showed that 39 hospitals adopted crms, while 56 did not. 'relative advantages', the 'size of the organisation', the 'is capabilities . this study found that most of the hospitals only used web-based crm. furthermore, the results showed that 'organisations' and 'technology' significantly influenced the adoption of crm. the authors found the external factors to be insignificant. also [89] examined the relationship between crms adoption, perception and organisation performance. a 103-survey of the top management in various hospitals was also conducted and found (i) a significant relationship between organisation performance and crms adoption, and (ii) a significant relationship between crms adoption and crms perception. in light of the above, the majority of studies regarding the three main categories of crm (e-crm, implementing and adopting crms) were able to produce positive outcomes for patients, medical professionals and healthcare organizations. to offer a better illustration and respond to our three research questions (rqs), tables 6-8, provide a summary details of each crm category. these include year, author, brief description, participants, settings and the methods of data collection which directly respond to rq2. to answer rq3, we assigned plus (+) and minus (−) symbols to the findings column which indicate the positive and negative outcomes of each study. 4. discussion our analysis of the current literature indicates that there are significant gaps in knowledge regarding crm in the healthcare environment. we found three main crm research categories: (1) e-crm (n = 5, 26%); (2) implementing crm (n = 11, 58%); and (3) adopting crm (n = 3, 16%). we proposed an introductory framework that organises all three aspects. fig. 9 presents a framework for categorising crm research in the healthcare environment, beginning with social web-based crm (e-crm). this means that all crm applications, functions and features are used through the internet environment. this also suggests that hospitals should manage all forms of communication and relationships with their patients through web 2.0 and social media technologies. consistent with this, kohli et al. [69] explored a web-based crm application called a pps, finding positive results in several areas, such as the physician-hospital relationship, medical operations, patient satisfaction, and clinical outcomes (especially in nutrition and neurology). however, the results of this study were based on physician case studies, and empirical data from a cost/benefit analysis of pps performance during and after its implementation. it would have been more efficient if patients were involved in the case study, to know whether executing pps had a direct influence and/or relationship with patients. adding to this, anshari et al. [70] proposed a crm 2.0 model to determine patient expectations of e-health services. this study also showed a positive outcome regarding empowerment of patients through the web, given that more than 70% of participants (patients) wished to view their electronic medical records online, as well as make appointments and payments, and obtain consultations and referrals. only one study proposed a framework for establishing social crm (i.e. ecrm), and identified key factors based on importance and priorities [71] . hence, more research is needed to better understand this element in healthcare organisations. our analysis and evaluation revealed that (i) physician interaction, cleanliness, and nursing were the most significant factors that influenced patients' choice of hospital, patient satisfaction, and service quality (sq). (ii) paediatrics, cardiology, and neurology were the most significant medical preferences and key competitive advantages obtained by hospitals. (iii) management (i.e. support and involvement), resources (i.e. it infrastructure), and employee training factors were the most substantial aspects that influenced the implementation of crm systems, as well as e-crm. (iv) hospital size, the medical staff's is capacity, and knowledge management (km) capabilities were the most significant factors that impacted the adoption of crm systems. (v) collecting patient's data was the most executed crm feature in the healthcare environment, while data analysis was the most underachieved. this appears to be the first systematic review to comprehensively synthesise and summarise the empirical evidence available for crm research in the healthcare environment. our search strategy was broad, examining several databases, search engines, platforms and academic journals, striving to find published and unpublished studies based on various crm concepts, locations and settings. for each selected study, we provided a critical appraisal of its methodology and data, sampling, data analysis, ethics and bias, findings and implications and usefulness. in addition, we highlighted each study's methodological strengths and weaknesses. we have also identified studies with positive and negative outcomes, which will help hospitals and policymakers to better understand the benefits of implementing crms. despite its strengths, our study also faces some limitations. first, we believe that the matter of the potential exclusion of studies that were not in english and from conference proceedings has been addressed at academic gatherings and in other languages, such as chinese and french. second, our critical appraisal showed the quality of selected studies varies from 'fair' to 'poor'. however, our sensitivity analysis did not show that excluding conference proceedings and including 'poor' quality studies affected our results. last, our review may have a publication bias because studies with positive outcomes are more frequently published than negative ones; however, the studies that we found that had positive outcomes had several weaknesses in terms of methodology, sampling, and data analysis. we suggest the population-intervention-comparison-outcome (pico) framework (see table 9 ) to help scholars form research questions when planning future investigations involving crm in the healthcare environment. according to [90, 91] the pico framework is widely used in medical/healthcare informatics and health research to help state the terms of reference, define the scope and manage research questions, search strategies, and eligibility criteria. our analysis showed that issues such as the privacy and security of patients, and their roles in crms development, were not yet table 6 summary of e-crm studies in healthcare year author brief description findings explored e-crm through pps, and performed costbenefit analysis on the quality and performance of pps. case study. physicians. table 7 summary of studies related to implementing crms in healthcare. year author brief description 2012 [78] adopted ssdm to evaluate the steps of implementing crm, which involved 4 phases and 10 systematic steps. case study --health examination organisation (+)all developed procedures positively measured/evaluated crm models, improved efficiency, and provided better services for health organisations. 2012 [79] explored 2013 [80] applied the is success model to assess crm from 3 aspects (i) system characteristics, (ii) users, and (iii) performance. survey crms user. health promotion centre (+)of system characteristics, only iq and sq had a significant influence on and relationship with perceived usefulness and user satisfaction. (+)perceived usefulness and user satisfaction had a significant effect on personal performance, as well as an indirect influence on organisational performance. 2013 [77] adapted a value characteristic framework to support crm implementation based on aspects of cm, dm, and csm, and linked each characteristic to a specific crm solution type. survey (in-depth) *manager. investigated by the selected studies. today, more and more of patient personal and health information (phi) is being stored in crms, many of these data are created by doctors, clinics and hospitals and they offer plenty of advantages such as reducing medical mistakes, sharing information easier and offering better care. whether phi is maintained in a paper record or an electronic health record, patients have the right to keep it private, and that privacy is protected by laws called health insurance portability and accountability act (hippa) [92] and general data protection regulation (gdpr) [93] . these laws require that certain healthcare providers keep phi private and secure encrypted form and proper journalised history from its inception. firewalls, strong encryption, secure login, access control and authentication mechanisms are some of the security measures that healthcare providers may or should use to protect the privacy of patients when implementing crms. as patient's privacy continues to evolve, certain policies and guidelines need to be followed to properly control access, disclose and protect phi under all circumstances to avoid misuse and litigations. hence, we suggest that future research further focuses on patient public and private information, privacy and security perceptions and how these might influence the implementation and adoption of crms in open environments. our results also revealed that only organisational and technological factors have been examined using a quantitative method (such as survey), with no formidable theoretical base used (except for 4 studies, which applied the is success model and toe theory). we encourage researchers to use different methods more readily to explore other potential factors such as culture and trust to determine how they might influence decision-making, and also to apply a greater variety of theories. with the increasing number of wearable devices, smart phones and mobile applications (apps), ict services, the mobile health (mhealth) domain is rapidly developing and gaining momentum at rapid speed as can be observed during the global 2020 coronavirus (convid19) spread. yet, none of the included studies have addressed mobile crm (m-crm) in health care in a consistent and systematic manner. many studies on mobile health have showed promising results in heart pace monitoring, body weight, blood pressure, and heart disease monitoring [94] . we believe patient with chronic illness could greatly benefit from m-crm in multiple ways, allowing for immediate medical responses and new symptom and diagnoses detection methods and procedures. therefore, we recommend more research that addresses m-crm in healthcare functionality and the issue of privacy and security of both patients as well as all healthcare workers. this might also require a set of de facto and/or international standards to be developed not only in m-crm and e-crm domains but everything spanning this phenomenon. in this study, we aimed to review, categorise, summarise, synthesise, and appraise crm research in the healthcare environment. this slr was performed by following the criteria of preferred reporting items for systematic reviews and meta-analysis (prisma) [61, 62] . our initial search identified 1,642 records, and 40 further studies from manual journals and reference lists search. our search and selection process went through different phases to degrade the findings. in total, 19 studies were carefully identified and analysed. each study was evaluated by following the criteria of quality assessment tools for undertaking a systematic review of disparate data developed by hawker et al. [66] . the findings were qualitatively and quantitatively organised based on three main research categories; e-crm (web-based crm), implementing crms, and adopting crms. the selected studies were published between 2000 and 2020. our results indicate that research and development on crm within the healthcare environment is still in its early stages in uncharted waters, and more research would be helpful. this slr provides several insights and recommendations for researchers, healthcare institutions, service providers, policymakers, table 8 summary of studies related to adopting crms in healthcare. year author brief description participants size (n) settings examined key factors for adopting crms and proposed an integrated model that incorporated two components (i) characteristics of crms and (ii) characteristics of organisation. 2015 [89] examined the relationship between crms adoption, perception and organisation performance. top management. 103 hospital. (+)significant relationship between organisation performance and crms adoption were found. (+)significant relationship between crms adoption and crms perception were also found. sample size (n), positive result (+), negative result (−). ict developers and suppliers. the authors, individually or jointly, have no institutional, financial and personal relationships with other persons, organizations and sponsoring or funding agencies, other than acknowledging such agencies in the manuscript for their generosity funding the research work upon which the manuscript is based. in addition, we hereby declare that the manuscript has not been submitted to any other journal, conference proceedings or books for publication. it is solely the work of the authors. the authors declare that there is no conflict of interest regarding the publication of this paper. electronic medical records (emr); and electronic patient records (epr). patient satisfaction; patient loyalty; relationship and communication; medical staff satisfaction; service quality; health outcomes; chronic illness. anticipating mismatches of hit investments: developing a viability-fit model for e-health services identifying opportunities for inpatient-centric technology healthy and active ageing: turning the 'silver'economy into gold' economic governance: helping european healthcare systems to deliver better health and wealth? suggestions for health information technology trials for respiratory disorders in low-and middle-income country settings: what can we learn from trials in high-income country settings? hit and mis: implications of health information technology and medical information systems systematic review: impact of health information technology on quality, efficiency, and costs of medical care it's more than just use: an exploration of telemedicine use quality can electronic medical record systems transform health care? potential health benefits, savings, and costs implementation of an electronic health records system in a small clinic: the viewpoint of clinic staff physicians' beliefs about using emr and cpoe: in pursuit of a contextualized understanding of health it use behavior a review on systematic reviews of health information system studies collaborative healthcare system between clinics and hospitals in malaysia fostering health information technology in small physician practices: lessons from independent practice associations healthcare professionals' adoption of clinical it in hospital: a view of relationship between healthcare professionals and hospital understanding physicians' adoption of electronic medical records: healthcare technology self-efficacy, service level and risk perspectives customer relationship management in healthcare consumer health informatics: health information technology for consumers engaging health care consumers to improve the quality of care how patient-centered healthcare can improve quality critical factors of hospital adoption on crm system: organizational and information system perspectives developing patient-based marketing strategies application of customer relationship management in health care patient relationship management in public healthcare settings service quality and customer lifetime value in professional sport franchises customer empowerment and relationship outcomes in healthcare consultations crm implementation in indian telecom industry-evaluating the effectiveness of mobile service providers using data envelopment analysis managing customer relationship management projects: the case of a large french telecommunications company an e-crm application in the telecommunications sector: a case study from greece encouraging crm systems usage: a study among bank managers measuring effectiveness of customer relationship management in indian retail banks factors and barriers affecting the implementation of crm-taiwan banking industry the implementation of crm in city commercial banks crm collaboration in financial services networks: a multi-case analysis customer relationship management: a case study of a greek bank quality and customer relationship management (crm) as competitive strategy in the swedish banking industry the state of crm adoption by the financial services in the uk: an empirical investigation crm systems and organizational learning: an exploration of the relationship between crm effectiveness and the customer information orientation of the firm in industrial markets an empirical study of customer relationship management implementation in taiwan's machine industry crm in the public sector: towards a conceptual research framework, proceedings of the 2005 national conference on digital government research crm success factors in software services firm: a case study analysis prioritization of effective factors on crm implementation in parsian international hotels company in tehran the effect of crm use on internal sales management control: an alternative mechanism to realize crm benefits the acceptance and use of customer relationship management (crm) systems: an empirical study of distribution service industry in taiwan a successful crm implementation project in a service company: case study smart homes and home health monitoring technologies for older adults: a systematic review investigating the effectiveness of technologies applied to assist seniors: a systematic literature review desmartis, m-health adoption by healthcare professionals: a systematic review barriers and facilitators to exchanging health information: a systematic review the effectiveness of information technology to improve antimicrobial prescribing in hospitals: a systematic review and meta-analysis innovative information visualization of electronic health record data: a systematic review classification of antecedents towards safety use of health information technology: a systematic review the use of technology for urgent clinician to clinician communications: a systematic review of the literature success criteria for electronic medical record implementations in low-resource settings: a systematic review effects of health information technology on patient outcomes: a systematic review the impact of clinical leadership on health information technology adoption: systematic review impacts of structuring the electronic health record: a systematic review protocol and results of previous reviews customer relationship management mechanisms: a systematic review of the state of the art literature and recommendations for future research synthesising qualitative and quantitative health evidence: a guide to methods: a guide to methods systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field preferred reporting items for systematic reviews and meta-analyses: the prisma statement the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration synthesising qualitative and quantitative evidence: a review of possible methods realist review -a new method of systematic review designed for complex policy interventions testing methodological guidance on the conduct of narrative synthesis in systematic reviews effectiveness of interventions to promote smoke alarm ownership and function appraising the evidence: reviewing disparate data systematically cochrane handbook for systematic reviews of interventions a conceptual model for acceptance of social crm systems based on a scoping study managing customer relationships through e-business decision support applications: a case of hospital-physician collaboration customer empowerment in healthcare organisations through crm 2.0: survey results from brunei tracking a future path in e-health research a framework for e-crm implementation in health service industry of a developing country investigating the crucial factors affecting the social crm implementation and its benefits in iraqi healthcare industry malaysia doctoral consortium for information systems, association for information systems -malaysia chapter factors influencing customer social relationship management implementation and its benefits in healthcare industry establishing customer relationship management framework in nursing homes avoid the four perils of crm creating customer knowledge competence: managing customer relationship management programs strategically adapted customer relationship management implementation framework: facilitating value creation in nursing homes developing a customer relationship management model for better health examination service comprehensive prioritized perspectives of crm system for implementation in the developing countries' hospitals information system success model for customer relationship management system in health promotion centers an evaluation of customer relationship management in hospital-based and privately run nursing homes in taiwan crm: conceptualization and scale development analysis of customer relationship management in hospitals and present an efficient model for crm implementation in hospitals modeling customer relationship management pattern using human factors approach in the hospitals of tehran university of medical sciences study to analyze the variables that affect the crm implementation in the hospitals the impact of the customer relationship management on organizational productivity, customer trust and satisfaction by using the structural equation model: a study in the iranian hospitals impact of crm on hospitals: a study conducted to gain view of the practitioners working in various private and govt. hospitals in delhi. priyanka gandhi dr. neelam tandon assistant professor professor factors affecting customer relationship management perception: a study of jordnian hospital sector the effect of customer relationship management system adoption and perception on organization performance: study of jordanian hospital sectors how to do a systematic literature review in nursing: a stepby-step guide development of evidence-based clinical practice guidelines (cpgs): comparing approaches the health insurance portability and accountability act of 1996 (hipaa) privacy rule: implications for clinical research towards a gdpr compliant way to secure european cross border healthcare industry 4.0 mobile technology in health (mhealth) and antenatal care-searching for apps and available solutions: a systematic review he is currently pursuing the ph.d. degree in industrial science with the energy university (uniten), malaysia. he has published in journals and conferences. his research interests include technology acceptance, medical informatics, e-health sudan, and the ph.d. degree from universiti teknologi petronas, malaysia, where he is currently a senior lecturer with the computer and information sciences department and core research member of centre in research and data science (cerdas) he is research professor at universidade estadual do ceará, fortaleza, brazil with key research interest in advanced computer networking, internet of things, cloud computing, big data, predictive analysis, use of advanced computing techniques, impact of e-social networking, closing the digital divide ict gap and ict project management. he has published well-over 272 technical and scientific papers and co-authored three books he is currently a postdoctoral researcher with the energy university (uniten). he has published in journals and conferences. his research interests include emerging technology acceptance, user behaviour, adoption of information systems in organizations, the iot respectively. he is currently an associate professor with the department of computer science, community college, king saud university. he acts as the head of the informatics research group, and a member of the scientific council-king saud university. his main research interests span over it diffusion and innovation, information technology management, human behaviour modelling in technology usage his current research interests include e-systems (e-gov, e-health, and ecommerce), cloud computing, and big data he also served as head of postgraduate and laboratory services unit in the institute of energy and infrastructure (iei), head of water and environmental engineering unit in the department of civil engineering, and senior researcher for sustainable engineering group uniten this work was funded by the researchers supporting project (rsp-2019/102), king saud university, riyadh, saudi arabia. supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.csi.2020.103442. key: cord-348840-s8wjg4ar authors: cobrado, l.; silva-dias, a.; azevedo, m. m.; rodrigues, a. g. title: high-touch surfaces: microbial neighbours at hand date: 2017-06-25 journal: eur j clin microbiol infect dis doi: 10.1007/s10096-017-3042-4 sha: doc_id: 348840 cord_uid: s8wjg4ar despite considerable efforts, healthcare-associated infections (hais) continue to be globally responsible for serious morbidity, increased costs and prolonged length of stay. among potentially preventable sources of microbial pathogens causing hais, patient care items and environmental surfaces frequently touched play an important role in the chain of transmission. microorganisms contaminating such high-touch surfaces include gram-positive and gram-negative bacteria, viruses, yeasts and parasites, with improved cleaning and disinfection effectively decreasing the rate of hais. manual and automated surface cleaning strategies used in the control of infectious outbreaks are discussed and current trends concerning the prevention of contamination by the use of antimicrobial surfaces are taken into consideration in this manuscript. in spite of the growing global commitment towards an effective reduction of healthcare-associated infections (hais), it is unfortunately certain that such infections will continue to be responsible for very high morbidity, increased costs and length of stay (los) for the coming decades [1, 2] . among potential sources of pathogens causing hais, the most frequent are the patient's microbiota and the hands of healthcare personnel [3] . additionally, evidence that hightouch surfaces (hts) will work as an extra source of microbial pathogens accumulated over the years, e.g., several microorganisms can survive on medical equipment for hours to months, improved cleaning and disinfection of surfaces decrease the rate of hai, and hospital environmental screening results and the study of clonal outbreaks, all have given support to the role of contaminated hts in the transmission of pathogens between patients and healthcare personnel [4] . from surfaces, microbial transmission may occur either through direct patient contact or, indirectly, through healthcare personnel hands or gloves [5] . therefore, upon potentially preventable sources of microorganisms, contaminated hts deserve strong consideration. microbial pathogens most frequently involved in the contamination of hospital environmental surfaces are (methicillinresistant) staphylococcus aureus (mrsa), vancomycinresistant enterococci (vre), clostridium difficile, multidrug resistant gramme-negative bacilli (such as pseudomonas, acinetobacter and enterobacteriaceae), norovirus, coronavirus and candida species [6] [7] [8] [9] [10] . strategies for cleaning contaminated hts may include manual and automated techniques. wipes and cloths with application of detergents or disinfectants are examples of manual techniques, while automated methods may involve uv light, hydrogen peroxide, steam vapour, ozone and hins (high-intensity narrow-spectrum light). on the other side, in order to prevent contamination of hts, antimicrobial surfaces are being developed. the inhibition of microbial adhesion with repellent films is a possible strategy, as it is the surface treatment with antimicrobial coatings of silver, copper, polycations, triclosan, bacteriophages or, even, light-activated biotoxic radicals. the aim of this manuscript is to review the role of hightouch surfaces in healthcare-associated infections, from the aetiology to strategies for surface cleaning and addressing preventive trends. as early as 1972, spaulding proposed a classification of inanimate surfaces into three general categories based on the risk of infection if the surfaces were contaminated at the time of use [11] . these categories can be applied to devices or instruments as follows: critical (exposed to normally sterile areas of the body; require sterilization), semi-critical (touch mucous membranes; may be sterilized or disinfected), and noncritical (touch skin or come into contact with people only indirectly; can be either cleaned and then disinfected with an intermediate-level disinfectant, sanitized with a low-level disinfectant or, simply, cleaned with water and soap). in 1991, the cdc proposed environmental surfaces (floors, walls and other bhousekeeping surfaces^that do not make direct contact with a person's skin) as an additional category [12] . more recently, the cdc's and healthcare infection control practices advisory committee's guidelines for environmental infection control in healthcare facilities [13] divided surfaces into patient care items and environmental surfaces. environmental surfaces were further divided into medical equipment and patient room surfaces (table 1) . over the years, research has been done in order to better target room disinfection practices. following recommendations made by the cdc to clean and disinfect hts more frequently than minimal-touch surfaces, data published in 2010 by huslage et al., based on the real frequency of contact, defined the top five most touched surfaces in hospitals: bed rails, bed surface, supply cart, over-bed table and intravenous pump [14] . hts may be classified as non-critical items (the contact occurs with intact skin that effectively acts as a barrier to most pathogens, but not with mucous membranes) and must be subject to cleaning and disinfection procedures as recommended, but with no absolute need for sterilization [15] . many pathogens may thrive on healthcare-associated equipment and environmental surfaces. among such organisms, mrsa, vre, c. difficile, p. aeruginosa, a. baumannii, enterobacteriaceae, stenotrophomonas maltophilia, burkholderia cepacia, norovirus, coronavirus and candida spp. may persist and contribute to the infection risk to which patients are systematically exposed. several studies have demonstrated that basic cleaning leads to mrsa elimination from environmental surfaces and enhanced cleaning may terminate outbreaks in intensive care units, with cost savings of $45,000 up to $51,000 per year [16] [17] [18] [19] . recently, two studies reported positively about pulsed xenon uv and hydrogen peroxide methods to boost the decontamination of patient rooms, contributing towards a reduction of mrsa bioburden [20, 21] . its inherent ability to resist certain antimicrobial agents (such as cephalosporins and aminoglycosides) allied to a great capacity to acquire determinants of antibiotic resistance (like gene clusters of vancomycin resistance) turn enterococci into a versatile nosocomial multidrug-resistant pathogen. the number of vre infections has been increasing worldwide, most frequently afflicting patients with serious comorbidities or undergoing prolonged hospitalization [22] . vre are known to survive for a long time in the hospital environment. viability on surfaces may range from 5 days to 4 months [23] . moreover, enterococci are tolerant to heat, chlorine and some alcohol preparations, making them very resilient to conventional cleaning practices, thus becoming easily disseminated among healthcare facilities [24] . therefore, besides thorough environmental cleaning several times a day with disinfectants, vre management protocols should include strict adoption of contact precautions and implementation of comprehensive educational programs for staff [25, 26] . spores of c. difficile can hold on to a healthcare environment for more than 5 months [23, 27] . fortunately, the use of chlorine-releasing disinfectants reduces the amount of spores in the environment, with some evidence suggesting that it may reduce the risk of recurrence and transmission of c. difficileassociated infections [28] . transmission of p. aeruginosa may easily occur from contaminated sinks to hands of healthcare personnel during washing, since this organism may thrive in biofilms that are adherent to sink traps, pipes, water lines and hospital drains [29] , turning these fashion-organized bacteria more prone to resist to disinfectants [30] . additionally, p. aeruginosa can resist 6 hours to 16 months on dry inanimate surfaces [23] . programs to control transmission should include, therefore, repeated cleaning with chlorine-based disinfectants, physical removal of persistent biofilm, replacement of components whenever feasible and regular inspection [31, 32] . the increase in the number of hais caused by a. baumannii might be explained not only by its ability to persist from 5 days to more than 5 months in undisturbed surfaces of healthcare equipment [23] , but also by its high resilience to cleaning with conventional detergent and alcohol disinfectants [33] . hence, outbreaks in hospital or other healthcare settings are difficult to contain because of the easy environmental contamination by this pathogen [34] [35] [36] . targeted infection control measures may be needed, including intensive cleaning with sodium hypochlorite and subsequent measurement of cleanliness, hand hygiene training, adoption of barrier precautions and contact isolation, as well as patient surveillance [37, 38] . there has been a growing concern about klebsiella pneumoniae infections, mainly because of its extensive β-lactamase resistance. k. pneumoniae are usual colonizers of the human gastrointestinal tract, pharynx and skin that may cause wound infections, pneumonia and sepsis, particularly in immunocompromised patients [39] . more recently, given its wide dissemination and selective advantage to resist to carbapenem antibiotics, k. pneumoniae have been showing a propensity to cause outbreaks in healthcare institutions [40] . it is known that k. pneumoniae may survive for more than 30 months in the healthcare environment [23] and that the origin of some outbreaks has been related to sinks and related pipes [41, 42] . another member of the enterobacteriaceae family, serratia marcescens, are known to cause pneumonia, meningitis, urinary tract and bloodstream infections. mdr isolates, including colistin resistant [43] , have been responsible for serious outbreaks among intensive care units and critically ill neonates [44] [45] [46] . s. marcescens are known to survive up to 2 months on dry inanimate surfaces [23] and have frequently been recovered from water pipes and hospital disinfectants [47] . because of the easy transmission and environmental persistence of enterobacteriaceae in healthcare facilities, adequate solutions aiming its eradication should ensure comprehensive educational interventions, hand hygiene training, chlorine-based cleaning and even the replacement of sinks and pipes [42, 48, 49] . similarly to other bacteria, it can persist in biofilms that may turn cleaning products and disinfectants more ineffective [30] . long-term control of s. maltophilia will be dependent upon the integration of an efficient cleaning strategy into a targeted healthcare facilities maintenance program [50] . it is widely distributed in soil and water habitats and recent healthcare-associated outbreaks have been linked to b. cepacia persistence in disinfectants, drugs, medical devices (e.g., respiratory nebulizers), sinks and contiguous aerator filters [51] [52] [53] . strict and repeated cleaning and replacement of aerators with flow straighteners may be required to stop outbreaks [51, 54] . the origin of norovirus outbreaks in healthcare facilities has been traced not only to sites near bathroom showers and toilets but also to sites near patients, including clinical equipment (e.g., blood pressure and pulse oximeter monitors), thermometers, trolleys and soap and alcohol gel containers [55] . after suspected or confirmed case contact, use of soap and running water is recommended [56] , probably with a superior efficacy than ethanol-based sanitizers [57] . however, detergent-based cleaning may be insufficient to eliminate norovirus from the environment and, therefore, hypochlorite solutions of at least 1000 ppm for an appropriate contact time represent a better strategy for cleaning [56, 58] . human coronavirus, usually responsible for acute respiratory syndromes, have been causing increased concern due to contact transmission during healthcare-associated outbreaks. viral persistence on doorknobs and surgical boom shelves has already been identified, with a presumed viability of 48 h; scrupulous environmental cleaning is certainly highly advisable in reducing the spread [59, 60] . moreover, biocidal surfaces based on copper alloys are very effective in inactivating coronavirus and could be employed in high touch surfaces in order to prevent the transmission of this respiratory virus [61] . although candida spp. are more resistant to germicidal chemicals than most vegetative bacteria, there are no specific recommendations other than general healthcare surface decontamination with disinfectants. nevertheless, in order to control a recent outbreak by a mdr c. auris, measures implemented included isolation of cases and contacts, protective clothing, screening of all other ward patients, skin decontamination with chlorhexidine, environmental cleaning with chlorine-based disinfectants and hydrogen peroxide vapour [62] . a clinical alert issued in june 2016 by the cdc on the global emergence of invasive infections caused by the mdr c. auris recommended thorough daily and terminal cleaning and disinfection of patient rooms using an epa-registered hospital grade disinfectant with a fungal claim. preventing the environmental surface transmission of healthcare-associated pathogens general strategies based on patterns of microbial resistance to physical and chemical germicidal agents and on the instrument/surface classification, spaulding has proposed three levels of disinfection [11] : high-level disinfection, that inactivates all vegetative bacteria, mycobacteria, viruses, fungi and some bacterial spores by the action of chemicals such as glutaraldehyde, peracetic acid and hydrogen peroxide; intermediate-level disinfection, which is effective against vegetative bacteria, some spores, mycobacteria, fungi, lipid and medium size viruses, but not against all nonlipid and small size viruses (e.g., sodium hypochlorite, alcohols, some phenolics and some iodophors); and low-level disinfection, that inactivates vegetative bacteria, fungi, enveloped viruses and some non-enveloped viruses (e.g., adenoviruses) by the action of quaternary ammonium compounds, some phenolics and some iodophors [12] . in order to prevent the persistence of microbial pathogens on medical equipment and environmental surfaces, education of healthcare staff, checklists and assessment of the adequacy of cleaning (by direct observation, use of fluorescent markers, of atp bioluminescence systems, swab cultures or agar slide cultures) with feedback to the staff are general interventions that need to be implemented to improve the frequency of adequate cleaning [63] [64] [65] . as general principles, all patient care items should be cleaned and/or decontaminated before and after use, for all patients [66, 67] ; whenever these items come into contact with blood or other body fluids, stringent cleaning and disinfection is warranted before and after use [68] . manufacturers of medical equipment usually provide care and maintenance instructions regarding servicing decontamination, compatibility with germicidal agents and water-resistance. in the absence of such instructions, the cdc and the healthcare infection control practices advisory committee (hicpac) recommend non-critical medical equipment (e.g., stethoscopes, blood pressure cuffs, equipment knobs and controls) to be subject to low or intermediate-level disinfection after cleansing, depending on the nature and degree of contamination. for instance, ethyl or isopropyl alcohol (60-90% v/v) may be used to disinfect small surfaces (e.g., rubber stoppers of multiple-dose medication vials and thermometers) and surfaces of healthcare equipment (e.g., stethoscopes and ventilators) [69] , while for large surfaces it may be impractical due to the rapid evaporation of alcohol and absence of the adequate contact time [12] . as a whole, frequently touched environmental surfaces benefit from enhanced cleaning. routine decontamination and disinfection are practices normally included within institutional cleaning policies. nevertheless, evidence has been built in order to favour the use of less toxic detergents over disinfectants in non-outbreak situations, without losing cleaning efficacy or adding costs [70] . detergents are less likely to contribute to the accumulation or dispersal of tolerance or resistance genes among healthcare-associated microbial isolates [71, 72] . according to the cdc, for medical equipment (particularly in the case of monitor touch screens, controls and cables), a disposable plastic barrier protection can be useful whenever these surfaces, touched frequently by gloved hands, may become contaminated with body fluids or present difficulties to cleaning. manual cleaning the physical removal of soil is a very important step in the cleaning process since its presence will impede the microbicidal activity of disinfectants, if needed. in order to control the bioburden on regular wards, daily cleaning with neutral detergent wipes is usually sufficient. however, more attention is essential on high-risk intensive care units because of the easiness of microbial recontamination [73] . moreover, patients colonized or infected with specific pathogens may demand cleaning regimens with disinfectants with registered label claims [68] . after patient discharge, terminal or deep cleaning is usually performed by removal of all detachable objects from the room and systematically wiping all surfaces downward to the floor level, with detergent cloths or disinfectant wipes. new liquid disinfectants are under development and include: improved hydrogen peroxide disinfectants, effective in reducing bacterial levels on surfaces [74, 75] , related to fewer hais [76] and able to reduce contamination by mdr pathogens on soft surfaces such as bedside curtains [77] ; peracetic acid and hydrogen peroxide disinfectants, a sporicidal combination that was shown to lower bacterial levels on surfaces and to reduce the contamination by mrsa, vre and c. difficile as effectively as sodium hypochlorite [78] ; electrolyzed water (hypochlorous acid) disinfectant, which may reduce bacterial levels on surfaces near patients in a higher degree than quaternary ammonium disinfectants [79] ; further promising, electrolyzed water has been sprayed onto medical equipment (with a short contact time and without the need for wiping because no toxic residue remains on surfaces) with a reduction of aerobic bacteria and c. difficile spores [80] ; coldair atmospheric pressure plasma systems, which generate reactive oxygen species (ros) with bactericidal activity and have potential use as surface disinfectants [81, 82] ; nebulized polymeric guanidine, under investigation for its antimicrobial activity against several healthcare-associated pathogens [83] . together with disinfectants, novel materials for liquid application such as microfiber cloths or mops and ultramicrofiber cloths are under development. when used according to manufacturers' instructions, an increased cleaning efficacy is to be expected as compared to standard cotton cloths or mops [84] . automated cleaning on the pathway to improve quality and ease of cleaning environmental surfaces, considerable efforts have been dedicated towards the development of automated devices. however, because of yet unsolved safety risks, mainly for patients, automated solutions are invariably targeting terminal cleaning. in most instances, these solutions do not preclude preliminary manual cleaning of surfaces to remove residual debris and reduce the bioburden. the microbicidal effect of uv light has been in use for disinfection of environmental surfaces, instruments and air. by damaging the molecular bonds in dna, a reduction in contamination by mrsa, vre and c. difficile on high-touch surfaces has been achieved [85] . automated mobile uv light devices are easy to use, with minimal need for special staff training. nonetheless, several issues have been raised that may hinder its efficacy, namely, the time and intensity of light exposure and potential barriers that may exist between the lamp and its target surface. as such, uv light is regarded as an effective adjunct, but not a stand-alone strategy for disinfection [86] . by producing free radicals that lead to oxidation of dna, proteins and membrane lipids [87] , vapour and aerosol hydrogen peroxide systems have already been shown to be effective against mrsa, vre, mdr gramme-negative bacilli, c. difficile, viruses and fungi [88] [89] [90] [91] [92] [93] . this excellent wide spectrum antimicrobial activity is not without drawbacks, such as toxicity after accidental exposure, minor erosion of environmental polymers and damage of electronic equipment. in addition, there is the need for trained operators, long cycle times for disinfection and the cost is high [94] . experiments suggest that vapour-phase hydrogen peroxide is a more potent oxidizer of protein than liquid-phase hydrogen peroxide [87] and, when supplementing other strategies, microcondensation hydrogen peroxide vapour systems may have contributed to control outbreaks by mrsa, mdr grammenegative bacteria and c. difficile in intensive care units, surgical wards and long-term care facilities [89, [95] [96] [97] [98] [99] . a novel silver-stabilized hydrogen peroxide is under investigation for its enhanced biocidal activity towards gramme positive and negative bacteria capable of producing catalase, both in planktonic and biofilm cultures. silver probably helps to stabilize and target hydrogen peroxide to the bacterial cell surface acting, therefore, synergistically [100] . in fact, a previous report on the effect of a dry-mist system using a mixture of hydrogen peroxide (5%) and silver cations (<50 ppm) was effective in decontaminating burn patient rooms, as well as a fungal research laboratory: a reduction in growth of at least two log was observed for tested bacteria, mycobacteria and fungi [101] . steam cleaning is a non-toxic and rapid method that may reduce the total bioburden from environmental surfaces by more than 90% [102] , with effectiveness against mrsa, vre and gramme-negative bacilli [103] . concerns about security when steam is applied to electrical items such as switches and buttons and risk of burns and scalds when cleaning a crowded ward are the reasons precluding its widespread use in healthcare facilities [104] . the oxidizing capacity of ozone justifies its previous evaluation as a gaseous decontaminant for controlling c. difficile on environmental surfaces and e.coli in hospital laundries [105, 106] . while it seems highly effective against vegetative bacterial cells, a smaller impact has been found in case of bacterial spores and fungi [107] . moreover, corrosiveness and toxicity issues may restrain further the use of ozone in healthcare settings [108] . by targeting intracellular porphyrins that absorb the light and produce ros with bactericidal activity [109] , highintensity narrow-spectrum (hins) light stands as another light-based method with possible application for decontamination of high-touch surfaces, although its efficacy is lower than uv light. as clear advantages, hins light is safe for patients, allowing continuous decontamination of the clinical environment [110] and it exhibits a wide-range microbicidal activity that includes mrsa, p. aeruginosa and a. baumannii [111, 112] . however, hins light has yet to prove its effectiveness in clinical settings and benefits upon hai rates, given the small range of published studies [110, 112, 113] . antimicrobial surfaces instead of focusing on the reduction of the bioburden on surfaces solely by cleaning, there are solutions designed to prevent surfaces from working as a microbial reservoir and that may be used as an adjunct to other strategies in reducing hais. antiadhesive surfaces target microbial adhesion usually by the interaction of antagonist physicochemical properties. easy-clean surfaces that are hydrophobic repel bacteria better than glass-coated controls [114] , while hydrophilic surfaces favour water sheeting and subsequent cleaning. similarly, polyethylene glycol coated surfaces promote a hydrophilic interaction against bacteria, preventing attachment [115] . the use of diamond-like carbon films has already been tried for medical implanted devices such as joint prostheses and stents in order to repel microbial adhesion [116] . despite being non-toxic and appealing, the lack of biocidal properties may turn discouraging a more generalized implementation of such easy-clean technologies. currently, there are available antimicrobial coatings that can produce a microbicidal effect and could lead to an effective reduction of high-touch surface bioburden. for instance, inorganic metals have been investigated for a long time and it is known that silver binds with disulphide and sulfhydryl groups present in proteins of microbial cell wall leading to death [117] , inhibiting not only environmental contamination but also colonization of medical implanted devices [118, 119] ; copper and copper alloys may form reactive oxygen radicals that damage nucleic acid and proteins [117] and have already demonstrated a potent antimicrobial effect when applied to surfaces, reducing the rate of healthcare-associated infections [120, 121] . polycationic surfaces, such as those coated with polyethyleneimines, hydrophobically attract and kill bacteria by physically damaging the cell wall [122] . triclosan has been in use for more than 30 years in detergents, soaps and cosmetics. at lower concentrations, it is bacteriostatic by inhibiting an enzyme involved in fatty acid synthesis and, at higher concentrations, it is bacteric i d a l b y d e s t a b i l i z i n g m i c r o b i a l m e m b r a n e s . compatibilization of triclosan with polymers may extend the duration of its wide-spectrum antimicrobial activity [123] and could prove effective in reducing environmental surface load of pathogens. bacteriophages applied to surfaces and targeting specific microorganisms have been attempted and mixtures of phages have been further suggested in order to effectively reduce the environmental bioburden. particularly interesting in healthcare settings is the fact that mdr pathogens keep vulnerable to the lytic action of phages [124, 125] . light-activated antimicrobial surfaces, such as those coated with titanium dioxide and activated by uv light [126] , generate reactive oxygen radicals with nonselective toxicity towards both bacteria and yeasts [127] . similarly, photosensitized surfaces could reduce the healthcare bioburden without promoting microbial drug resistance mechanisms. although antimicrobial coatings may seem very promising, especially as an adjunct measure to more traditional and proven cleaning strategies, some concerns keep hindering its wider use in healthcare settings. robust cost-effectiveness studies are still lacking since reliable information about antimicrobial coatings durability, resistance and possible toxicity is yet somewhat insufficient [50, 68] . given the high morbidity and costs associated with hais, improved strategies are urgently needed to reduce effectively the rate of infection. certainly, one good step forward would be the blockade of transmission from environmental hightouch surfaces. at the moment, manual and automated techniques for cleaning surfaces exhibit variable success. concerns over durability, resistance and toxicity may be precluding a much wider application of the novel antimicrobial coatings. admitting an albeit limited performance of the traditional cleaning methods, the supplementation with newer technology should be indicated. hence, more randomized controlled trials and cost-effectiveness studies are needed and further investigation on antimicrobial surfaces is welcomed in order to face the challenge imposed by the global advance of antimicrobial drug resistance and the pressure to reduce bed turnover times with shortages in nursing personnel, housekeeping staff and budgets. funding none to declare. ethical approval this type of study does not involve human participants and/or animals. informed consent for this type of study, informed consent is not required. multistate point-prevalence survey of health care-associated infections point prevalence survey of healthcare-associated infections and antimicrobial use in european acute care hospitals epidemiology and control of nosocomial infections in adult intensive-care units the role of the surface environment in healthcare-associated infections cleaning hospital room surfaces to prevent health care-associated infections: a technical brief importance of the environment in meticillinresistant staphylococcus aureus acquisition: the case for hospital cleaning role of environmental contamination as a risk factor for acquisition of vancomycin-resistant enterococci in patients treated in a medical intensive care unit characterization of a hospital outbreak of imipenem-resistant acinetobacter baumannii by phenotypic and genotypic typing methods the role of environmental contamination with small round structured viruses in a hospital outbreak investigated by reverse-transcriptase polymerase chain reaction assay acquisition of clostridium difficile from the hospital environment chemical disinfection and antisepsis in the hospital chemical disinfection of medical and surgical material, in disinfection, sterilization and preservation guidelines for environmental infection control in health-care facilities. recommendations of cdc and the healthcare infection control practices advisory committee (hicpac) a quantitative approach to defining bhigh-touch^surfaces in hospitals guideline for disinfection and sterilization in healthcare facilities an outbreak of mupirocin-resistant staphylococcus aureus on a dermatology ward associated with an environmental reservoir control and outcome of a large outbreak of colonization and infection with glycopeptideintermediate staphylococcus aureus in an intensive care unit evidence that hospital hygiene is important in the control of methicillin-resistant staphylococcus aureus measuring the effect of enhanced cleaning in a uk hospital: a prospective cross-over study evaluation of a pulsed-xenon ultraviolet room disinfection device for impact on contamination levels of methicillin-resistant staphylococcus aureus controlling methicillin-resistant staphylococcus aureus (mrsa) in a hospital and the role of hydrogen peroxide decontamination: an interrupted time series analysis the rise of the enterococcus: beyond vancomycin resistance how long do nosocomial pathogens persist on inanimate surfaces? a systematic review emergence and spread of vancomycin resistance among enterococci in europe successful prevention of the transmission of vancomycin-resistant enterococci in a brazilian public teaching hospital epidemiology and control of an outbreak of vancomycin-resistant enterococci in the intensive care units use of purified clostridium difficile spores to facilitate evaluation of health care disinfection regimens efficacy of cleaning products for c. difficile: environmental strategies to reduce the spread of clostridium difficile-associated diarrhea in geriatric rehabilitation distribution and transmission of pseudomonas aeruginosa and burkholderia cepacia in a hospital ward bacterial biofilms in nature and disease outbreak of multidrug-resistant pseudomonas aeruginosa colonization and infection secondary to imperfect intensive care unit room design pseudomonas aeruginosa: a formidable and ever-present adversary the effect of terminal cleaning on environmental contamination rates of multidrug-resistant acinetobacter baumannii the epidemiology and control of acinetobacter baumannii in health care facilities acinetobacter baumannii: epidemiology, antimicrobial resistance, and treatment options acinetobacter outbreaks a multifaceted intervention to reduce pandrug-resistant acinetobacter baumannii colonization and infection in 3 intensive care units in a thai tertiary care center: a 3-year study management of a multidrug-resistant acinetobacter baumannii outbreak in an intensive care unit using novel environmental disinfection: a 38-month report epidemiology of klebsiella and hospitalassociated infections outbreak of a multiresistant klebsiella pneumoniae strain in an intensive care unit: antibiotic use as risk factor for colonization and infection an outbreak of multiply-resistant klebsiella pneumoniae in the grampian region of scotland minor outbreak of extendedspectrum beta-lactamase-producing klebsiella pneumoniae in an intensive care unit due to a contaminated sink outbreak of a cluster with epidemic behavior due to serratia marcescens after colistin administration in a hospital setting evaluation and comparison of random amplification of polymorphic dna, pulsed-field gel electrophoresis and adsrrs-fingerprinting for typing serratia marcescens outbreaks molecular epidemiology of an outbreak of serratia marcescens in a neonatal intensive care unit serratia marcescens: an outbreak experience serratia marcescens klebsiella pneumoniae producing kpc carbapenemase in a district general hospital in the uk decreased transmission of enterobacteriaceae with extended-spectrum beta-lactamases in an intensive-care unit by nursing reorganization hospital cleaning in the 21st century outbreak of burkholderia cepacia complex among ventilated pediatric patients linked to hospital sinks multi-institutional outbreak of burkholderia cepacia complex associated with contaminated mannitol solution prepared in compounding pharmacy an outbreak of burkholderia cepacia complex pseudobacteremia associated with intrinsically contaminated commercial 0.5% chlorhexidine solution uses of inorganic hypochlorite (bleach) in health-care facilities norovirus in the hospital setting: virus introduction and spread within the hospital environment guideline for the prevention and control of norovirus gastroenteritis outbreaks in healthcare settings effectiveness of liquid soap and hand sanitizer against norwalk virus on contaminated hands effects of cleaning and disinfection in reducing the spread of norovirus contamination via environmental surfaces middle east respiratory syndrome coronavirus on inanimate surfaces: a risk for health care transmission stability of middle east respiratory syndrome coronavirus (mers-cov) under different environmental conditions human coronavirus 229e remains infectious on common touch surface materials first hospital outbreak of the globally emerging candida auris in a european hospital identifying opportunities to enhance environmental cleaning in 23 acute care hospitals impact of an environmental cleaning intervention on the presence of methicillin-resistant staphylococcus aureus and vancomycin-resistant enterococci on surfaces in intensive care unit rooms modern technologies for improving cleaning and disinfection of environmental surfaces in hospitals cleanliness audit of clinical surfaces and equipment: who cleans what? healthcare equipment as a source of nosocomial infection: a systematic review controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination apic guideline for selection and use of disinfectants the crucial role of wiping in decontamination of high-touch environmental surfaces: review of current status and directions for the future promises and pitfalls of recent advances in chemical means of preventing the spread of nosocomial infections by environmental surfaces bacterial adaptation and resistance to antiseptics, disinfectants and preservatives is not a new phenomenon evaluation of the efficacy of a conventional cleaning regimen in removing methicillin-resistant staphylococcus aureus from contaminated surfaces in an intensive care unit efficacy of improved hydrogen peroxide against important healthcare-associated pathogens evaluation of a new hydrogen peroxide wipe disinfectant use of a daily disinfectant cleaner instead of a daily cleaner reduced hospital-acquired infection rates effectiveness of improved hydrogen peroxide in decontaminating privacy curtains contaminated with multidrug-resistant pathogens evaluating a new paradigm for comparing surface disinfection in clinical practice comparison of cleaning efficacy between in-use disinfectant and electrolysed water in an english residential care home effectiveness of an electrochemically activated saline solution for disinfection of hospital equipment cold air plasma to decontaminate inanimate surfaces of the hospital environment cold atmospheric pressure plasma and decontamination. can it contribute to preventing hospital-acquired infections? evaluation of the efficacy of akacid plus (r) fogging in eradicating causative microorganism in nosocomial infections microbiologic evaluation of microfiber mops for surface disinfection evaluation of an automated ultraviolet radiation device for decontamination of clostridium difficile and other healthcare-associated pathogens in hospital rooms applications of ultraviolet germicidal irradiation disinfection in health care facilities: effective adjunct, but not stand-alone technology use of hydrogen peroxide as a biocide: new consideration of its mechanisms of biocidal action controlling methicillin-resistant staphylococcus aureus (mrsa) in a hospital and the role of hydrogen peroxide decontamination: an interrupted time series analysis control of an outbreak of acinetobacter baumannii infections using vaporized hydrogen peroxide airborne hydrogen peroxide for disinfection of the hospital environment and infection control: a systematic review hydrogen peroxide vapour decontamination of surfaces artificially contaminated with norovirus surrogate feline calicivirus impact of hydrogen peroxide vapor room decontamination on clostridium difficile environmental contamination and transmission in a healthcare setting deactivation of the dimorphic fungi histoplasma capsulatum, blastomyces dermatitidis and coccidioides immitis using hydrogen peroxide vapor floor wars: the battle for 'clean' surfaces eradication of persistent environmental mrsa hydrogen peroxide vapour decontamination in the control of a polyclonal meticillin-resistant staphylococcus aureus outbreak on a surgical ward hydrogen peroxide vapor decontamination of an intensive care unit to remove environmental reservoirs of multidrug-resistant gram-negative rods during an outbreak impact of environmental decontamination using hydrogen peroxide vapour on the incidence of clostridium difficile infection in one hospital trust use of vaporized hydrogen peroxide decontamination during an outbreak of multidrug-resistant acinetobacter baumannii infection at a long-term acute care hospital antibacterial properties and mechanism of activity of a novel silver-stabilized hydrogen peroxide efficacy of hydrogen peroxide dry-mist disinfection system for hospital environment disinfection reduction in the microbial load on hightouch surfaces in hospital rooms by treatment with a portable saturated steam vapor disinfection system reduction in infection risk through treatment of microbially contaminated surfaces with a novel, portable, saturated steam vapor disinfection system hospital cleaning: problems with steam cleaning and microfibre ozone gas is an effective and practical antibacterial agent disinfection of hospital laundry using ozone: microbiological evaluation use of gaseous ozone for eradication of methicillin-resistant staphylococcus aureus from the home environment of a colonized hospital employee gaseous and air decontamination technologies for clostridium difficile in the healthcare environment helicobacter pylori accumulates photoactive porphyrins and is killed by visible light environmental decontamination of a hospital isolation room using high-intensity narrow-spectrum light high-intensity narrow-spectrum light inactivation and wavelength sensitivity of staphylococcus aureus inactivation of bacterial pathogens following exposure to light from a 405-nanometer light-emitting diode array clinical studies of the high-intensity narrow-spectrum light environmental decontamination system (hins-light eds), for continuous disinfection in the burn unit inpatient and outpatient settings self-cleaning coatings bacterial adhesion on peg modified polyurethane surfaces a review of modified dlc coatings for biological applications self-disinfecting surfaces: review of current methodologies and future prospects silver in health care: antimicrobial effects and safety in use dual-action hygienic coatings: benefits of hydrophobicity and silver ion release for protection of environmental and clinical surfaces copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit role of copper in reducing hospital environment contamination permanently microbicidal materials coatings triclosan antimicrobial polymers potential of bacteriophage phi ab2 as an environmental biocontrol agent for the control of multidrug-resistant acinetobacter baumannii antimicrobial surfaces and their potential in reducing the role of the inanimate environment in the incidence of hospital-acquired infections comparison of infectious agents susceptibility to photocatalytic effects of nanosized titanium and zinc oxides: a practical approach light-activated antimicrobial coating for the continuous disinfection of surfaces key: cord-024619-0wihqs9i authors: parvin, farhana; ali, sk ajim; hashmi, s. najmul islam; khatoon, aaisha title: accessibility and site suitability for healthcare services using gis-based hybrid decision-making approach: a study in murshidabad, india date: 2020-05-11 journal: spat doi: 10.1007/s41324-020-00330-0 sha: doc_id: 24619 cord_uid: 0wihqs9i healthcare accessibility and site suitability analysis is an elongated and complex task that requires evaluation of different decision factors. the main objective of the present study was to develop a hybrid decision-making approach with geographic information systems to integrate spatial and non-spatial data to form a weighted result. this study involved three-tier analyses for assessing accessibility and selecting suitable sites for healthcare facilities, and analysing shortest-path network. the first tier of analysis stressed the spatial distance, density and proximity from existing healthcare to find more deprived and inaccessible areas in term of healthcare facilities. the result revealed that spatial discrepancy exists in the study area in term of access to healthcare facilities and for achieving equal healthcare access, it is essential to propose new plans. thus, require finding suitable sites for put forward new healthcare service, which was highlighted in the second tier of analysis based on land use land cover, distancing to road and rail, proximity to residential areas, and weighted overlay of accessibility as decision factors. finally, in the third tier of analysis, the most suitable site among the proposed healthcare was identified using the technique for order of preference by similarity to ideal solution. the road network analysis was also performed in this study to determine the shortest and fastest route from these healthcare facilities to connect with district medical hospital. the present study found some suitable sites throughout the district on inaccessible zones where people are deprived from better healthcare facilities. this attempt will highly helpful for preparing a spatial decision support system which assists the health authorities regarding the healthcare services in inaccessible, underprivileged, and rural areas. electronic supplementary material: the online version of this article (10.1007/s41324-020-00330-0) contains supplementary material, which is available to authorized users. the terminology of accessibility possesses the multi-layered and multi-faceted concepts which ascertain the quality of admitting approaches which provide a range of support services. potential accessibility ensures the optimum access to comprehensive and quality healthcare to every single individual of a population within a short of healthcare service providers [1] . adequate accessibility to healthcare service is one of the vital elements for holding an advanced society status. thus, it holds a position in the 17th global targets set by the united nations for promoting sustainable development goals [2] . who under the human right concept describe accessibility as availability of health services within a safe and reasonable physical reach to all section of the population especially vulnerable and marginal groups likely ethnic minorities and indigenous people, women, children, aged groups and persons with disabilities including in rural areas [3] . a united states president's commission in 1983 sort to explain the meaning and electronic supplementary material the online version of this article (https://doi.org/10.1007/s41324-020-00330-0) contains supplementary material, which is available to authorized users. conceptual problem related to accessibility that equitable access to healthcare should be in a manner that every single citizen can acquire an adequate level of medical care without excessive burdens [4] . another commission came with a solution regarding the conceptual problems related to access and gave a comprehensible answer that the concept of accessibility is as important as the usage of service for health outcomes. their definition relies on both the concept of timely use of healthcare services and on the best possible use of health outcome [5] . in a society, expenditure on healthcare is considered as the best social investment as healthy society is one of the fundamental aspects of development to promote social well-being and to minimize health disaster risk in many developing countries [6, 7] . in india, despite economic advancement, inequality in healthcare is one of the primary challenges to meet development goal [8] . several committees are set up to recommend public health policy aims to provide high-quality equal healthcare service to all likely bhore committee 1946, ministry of health and family welfare 2012, national urban health mission 2013 [9] . despite all these efforts, a recent health survey reveals that only about 29% of indian population is served in government hospitals and about one-fourth income of each household has been invested in healthcare services [1] . many studies attempt various techniques to get a clear understanding of the accessibility to healthcare centre and to delineate the deprived regions of these healthcare facilities [10] . geospatial techniques are widely used in different field of studies related to healthcare for maximizing the geographical accessibility to medical services [11] . gis is a platform which provides a framework in relation to the population for both assessments of the distribution of healthcare centres and evaluation of effective coverage [12] . spatial or geographical accessibility generally refers to the physical access of a user to a provider's location [13] or simply reflect the linkages between the point of supply and point of demand by taking consideration of existing transport framework and travel impedance [14] . accessibility is a multidimensional concept which inherent both spatial dimension such as availability, accessibility and non-spatial dimensions like affordability, acceptability and accommodation [15, 16] . khan [16] highlighted the vehicular travel time/distance and euclidean distance for characterising spatial attributes to measure spatial accessibility. spatial separation based model is a suitable approach when there is incomplete and lacking transport network data and give desirable result for accessibility operation by using the physical distance between infrastructures as it only uses the location of services of interest [17] . cumulative opportunity or isochrones approach is an effective method as it considers the elements of travel time as well as maximum desirable travel time by capturing land use pattern and infrastructural barrier across the land cover. gravity model is another model for operating accessibility provides the size of the zone of interest, the configuration of the zone, choice of attractor variables and the values of travel impedance time. besides these approaches, the two-step floating catchment area was (2sfca) proposed by luo and wang for calculating spatial accessibility [18] . in this method, a floating catchment area is selected as a window to measure serviceto-population ratio for each healthcare service. after that, the entire ratio is summed up for each point of location within the catchment area and use it as an accessibility index of that location. enhanced two steps floating catchment area method come to overcome the rigidity and arbitrariness of the 2sfca i.e. it does not take into account the distance decay method, it sets catchment and subzones of healthcare by considering travel time or travel distance based on the road network is often used as the spatial barrier or impedance [19] . three steps floating catchment area method used by rekha et al. [1] to calculate accessibility by considering three attributes namely attractiveness of health services, travel time and distance between the location of the service centre and the location of residents and population demand for healthcare facilities. these all techniques have its advantages in term of application but the result will be incredible if geographic information system (gis) integrated for the spatial result. gis application in healthcare accessibility measurement is exclusively popular for two decades [20] . gis is one of the sophisticated spatial analyst techniques that not only potential to identify demand flexible points based on residential clustering but also pinpoint spatial inequalities in healthcare delivery points and provide suitable locations for new health facilities [11] . the geographical dimension of access can be authentically expressed by gis and appreciate the fact that gis technique has potential to fit in a wide range of aspects such as identification of vulnerable population who are devoid of service reach, delimit the points of quality service and treatment without looking at the loopholes in previous qualitative research [21] . several studies found that gis technique is very useful in the demarcation of nearest healthcare centre for different road network by using patient's postal/zip code and converted then into grid reference to find straight line or travel time distance [11, 22] . geographical information system applied to measure the relative importance of distance on providers to gain treatment for depression and also tried to understand the barriers regarding the adaptation of such medical facilities in rural as well as urban areas [23] . distance and travel time are the most important factor for serving people because the number of death increases with increasing travel time to a hospital in a region [24] . gis offers a distance tool to estimate travel time between healthcare and residential premises and also deals with the shortest and fastest path analysis to reach nearby healthcare in a short time interval. looking towards such advantages of geographic information system and geospatial analysis, the present study also emphasized and applied a hybrid decision-making approach with the support of gis. the present study aimed to utilize spatial tools to integrate different spatial and aspatial information for spatial analysis of healthcare accessibility and inaccessibility which support to propose new health infrastructures in inaccessible areas in murshidabad district of west bengal, india. such type of geospatial analysis for healthcare accessibility would be applied for identifying suitable sites and allocating new service areas, determining most ideal sites where allocation requirement has essential, and estimating the shortest and fastest distance between nodes of healthcare facilities. the study also offers assistance to health authorities to understand spatial pattern and distribution of healthcare availabilities and facilities for better service to inaccessible and deprived areas. murshidabad district (west bengal, india) is one of the classical provinces with rich historical background and also an important unit of the state, as it shares the largest international boundary with bangladesh in its eastern part. it is the northernmost district of presidency division of west bengal geographically lying between 238 432 0 n and 248 52 0 n and 878 49 0 e and 888 44 0 e (fig. 1) . the district hq is behrampore. the district is boarded by burdwan and nadia district in the south and birbhum district and jharkhand state in the west and malda district in the north. river bhagirathi divides the entire district almost two equal parts, popularly known as 'radh' on the western side and 'baghri' on the western side. the total area of the district is 5324 km 2 and holds the 7th largest position among the districts of the states in terms of land area. according to the 2011 census, murshidabad district is home of around 7,102,430 people which is roughly equal to the total population of bulgaria and united states of washington [25] . population density of the district is 1334/km 2 and the decadal growth rate is 21.07%. the district has a large concentration of minority population which accounts 66% of the total population of the state where the majority are muslims; the sex ratio is 957 per 1000 males and literacy is 67.53% with a male and female literacy rate of 69.95 and 63.09 respectively. this district is a rural unit and a large number of the total workers accounts for 34.77% of the total population engaged in other works such as labourer [26] , followed by agricultural labourers i.e. 32.52% and household industry workers contributing to 17.99%. the above statistics on literacy, male-female ratio of literacy, and worker pattern indicate that this region is not well developed in term education and occupation. as far as the healthcare facilities are concerned, the district depicts a deprived health service profile where only one medical college and hospital is situated with a bed occupancy rate of 139.8. there is only three super-specialist hospital and four sub-division hospitals are present with a bed occupancy rate of 97.5 and 127.55 respectively [27] . rural hospital and public healthcare are also available but the service qualities are not well. moreover, the accessibility of these healthcare facilities is also a vital concern and need to bring focus on proper access to present institutions and also the elimination of disparity region. accessibility has a shorthand terminology with longhand sets of assignments for potential utilization of healthcare services which estimates the degree to which all individual of a population can reach needed services present within the defined distance or driving time. availability, affordability is another important component of healthcare utilization. optimal exercise of healthcare facilities assessment is not an easy task and can be done by estimating location-based accessibility and individual-based accessibility. spatial distribution of public health services illustrates a healthcare profile of any space. murshidabad district has an average portrait of medical services where availability of health institutions is not quite unacceptable but accessibility in terms of a positive outcome is not adequate. a positive outcome can be assessed through efficient treatment, adequacy of a speciality hospital, proper diagnostic and treatment skills of the provider. lack of this positive outcome makes an accessible profile of the district poor. murshidabad district come under the medium-to-low accessible zone for health service if only availability of medical institution will be the criteria but spatial location (distance, travel impedance, travel cost etc.) of the healthcare centres also a vital element for driving accessibility. the district has many government hospitals and public nursing homes under different categories such as one medical college and hospital, super specialist hospitals, sub-divisional hospitals, rural hospitals, and nursing homes. murshidabad district has 26 blocks under 5 subdivisions where the spatial distribution of healthcare centres is not advantageous as there is a trend of clustering can be found. maximum clustering of medical centres is found in certain blocks only such as behrampore, murshidabad-jiaganj, domkal, raghunathganj-i (table 1) . behrampore block is the highest accessible area of the district where a cluster of many medical institutions are placed including medical college and hospital, public healthcare centres. suti-i, raghunathganj-ii, sagardighi, bhagwangola-ii, raninagar-ii, jalangi and bharatput-i blocks are the most inaccessible units of the district where a number of medical institution are very limited and rest of the block has moderate healthcare accessibility in terms of total medical institution establishment [26] . healthcare accessibility is also illustrated by the efficiency of services which depends on the availability of the doctor. doctor-patient ratio is one of the most important mediating factors for individual-based accessibility. overburden of patients can lead to inappropriate treatment regimens due to inadequate doctor availability. out of 26 blocks, only 6 blocks possess good accessibility such as behrampore, raghunathganj-i, murshidabad jiaganj, domkal, kandi, beldanga-i blocks contains a good number of doctors among them behrampore has the highest number of doctors i.e. 241. remaining blocks have an inadequate number of doctors and possess low accessibility characteristics [26] . a number of patients are another accelerating factor for visualization of healthcare status. behrampore block is still in the highest position in terms of a number of patients comes for treatment. a large number of patient in any healthcare centre can depict bilateral assumptions as one can be the better medical service attract the most of the patient and other can be the lack of sufficient medical institution can lead to high occupancy and burden rate. in the case of murshidabad district, the second one can be the accelerating factor. murshidabad-jiaganj, rghunathganj-i, kandi, nawda have experience high accumulation of patients, while raninagar-i, domkal, hariharpara, beldanga-i, nabagram have a medium rate of patients crowd. rest of the blocks such as farakka, samserganj, suti-i and ii, raghunathganj-i and so on have comparatively less number of patients as most of the patient use cross-border medical facility due distance from district medical college and hospital. although potential accessibility of healthcare service can not only be measured by single criteria or indicator as all the indicators are interdependent to each other to accelerate higher accessibility. an adequate number of the medical institution with sufficient appointment of doctors available to fulfil patients medical needs can promote higher healthcare status of any unit, if one indicator overburdens the other, the balanced will disturb and can be a dynamic force for inaccessibility. for this purpose, a relative accessibility index (rai) is a crucial factor for assessing the rate of accessibility of any region. murshidabad district has possession of low relative accessibility index. only a few pockets have high relative accessibility index such as behrampore (highest), murshidabad-jiaganj, and domkal, while rest of the blocks have low to very low status in terms of rai (table 1 ). access to healthcare is a multi-fold concept and it mainly corresponds with many dimensions like availability, affordability, acceptability and geographical accessibility of the services. geographical accessibility and availability of healthcare services contain spatial dimension which can be analysed by geographical information system while the rest two i.e. affordability and acceptability are non-spatial dimensions. many types of research have been done to achieve higher accessibility to healthcare service mainly under the four notions: distance from the system works under two concepts i.e. nearest service centre to the population and average distance to the set of service centres, the threshold of the service, gravitational models for providers. distance is the major element to calculate higher accessibility to the service. sometimes it can be measured trough nearest location to the population, travel cost, travel time. nearest the location of a service centre lesser the travel time and will minimize the travel cost, ultimately provide higher accessibility. travel cost and the travel time will also be considered as an important element to measure the non-spatial dimension. geographical information system (gis) studies commonly used euclidean distance method to calculate nearest the location of a service centre i.e. distance from a population centre [1] . this method faces drawback to provide suitable site mainly in urban areas where the population enjoys sets of service options within a certain point or point of reference. thus, average travel impedance to the service will be suited to ensure spatial accessibility as it incorporates both the entities; accessibility and availability to the population. the threshold of the service can be calculated by several patients per medical institutions. it also refers to the supply options which incorporates doctor-patient ratio, number of bed per person. this method can be shown by density analysis (point, line, kernel density) in gis researches. this method also has some demerits as it does not consider the cross-border population demand to reference supply point. the gravity model is an updated version on newton's law of gravity to analyse the spatial accessibility. this model overcomes the problems associated with former dimensions. it incorporates accessibility and availability of services within both rural and urban settings. it also helps to set the potential supply options to a certain set of potential population point. this model is thus: but the main problem with this is the distance decay coefficient b, which is usually not known and expressed in term of linear or exponential. two-step floating catchment area model: floating catchment area model was primarily employed by peng to analyse urban employment accessibility and further luo and wang also used this method to overcome problem arise for the gravity-based model to calculate spatial accessibility like quality and spatial resolution [1] . in this method, a catchment area selection is required based on distance and travel time and a spatial accessibility value is appointed for each population point by adding up to the service-population ratio of all the catchments overlay on the point. following is the equation for measuring two-step catchment areas: for population point: where p k is the population size at point k, h j is the doctorpatient ratio, s j is the capacity of a particular healthcare centre, d o is the minimum travel time. but this method is imitated on selected catchment areas and not suitable for all areas. spatial accessibility value at the centre and periphery is higher and becomes zero just over the line. an intervention like flexibility in travel time can make variations in estimated spatial accessibility value. thus, a more improved method is needed to overcome this problem. enhanced two-step floating catchment area model: in this model, the whole catchment area is divided into several subzones with a distinct weight for accessibility, instead of fixing particular binary accessibility for the entire catchment area. following is the equation for computing this method: where p j is the doctor-patient ratio, s j is the capacity of the healthcare centre measured by bed availability or the number of doctors and w r is the accessibility weight appointed for each subzone depended on the distance d between the facility and population and also depend on intervention coefficient. this method also has certain limitation such as it does not take into account the fact that competition among the healthcare centres situated in a single catchment area. thus, some modification has to require and need to develop a more improved version. three-step floating catchment area model: this model is the extension of the previous method. the catchment area is devoted to each healthcare facility as well as population. it takes into account the travel distance and travel time for computing accessibility weight for each catchment (healthcare site) area. to overcome the problem of assigning equal accessibility value to each medical institution, a comparison weight is assigned to each healthcare service based on travel distance and time t d . where w ij and w ik are gaussian weights for service site j and population site k. this selection weight was further taken up in the subsequent formulas used to compute the doctor-patient ratios and the accessibility score as: for each service site: for each habitation: where s j is the capacity of the health care facility j, p j is the threshold of the service computed for each health care facility, p k is the population of habitation k and w r is the weight computed for each habitation and health care facility. but this technique also has some drawback and not satisfactorily accepted because only aspatial data have considered here but the availability of spatial data i.e. no. of health institutions in a particular area, the distance among them, density of health care in a particular area are not considered. thus, a new and hybrid approach is required through which spatial and aspatial information can be analysed, assessed and evaluated for a whole geographical area. to overcome all these problems present study tried to prepare a hybrid decision-making approach for higher healthcare accessibility assessment. in recent times, the geographical information system (gis) is used to prepare a hybrid model in which all aspects can be covered and merged for analysis. the present study has been carried through several steps to precede the decision-making approach. firstly, relative accessibility index (rai) has been estimated based on the existing situation and available data on no. of the medical institution, number of patients and number of doctors i.e. doctor-patient ratio. the rai of health care facilities is the indication of the areal proportion of health facilities which help in analysing accessibility and inaccessibility. for the same, euclidean distance, kernel density and proximate had been analysed to support suitability analysis of healthcare sites using the weighted linear combination. parallelly, topsis was applied to ascertain the most suitable sites where new health care facilities could be built to reach maximum people to provide better health service. finally, the shortest path network analysis was measured to connect and interlinked between existing and proposed healthcare. initially, to start the first hierarchy of decision making approach the relative accessibility index was calculated. it is obtained using the following equation: where mi is the no. of the medical institution, pi is the no. of patients, dj is the availability of doctors and h is the constant equal to 100. euclidean distance was measured among each healthcare presently existed. it is a measure of the true straight line distance estimation between two points 'x' and 'y' in euclidean space or along the 'x' and 'y' axis. it can be described by is putting pythagora's theorem in one dimensional and two-dimensional spaces where there is one variable describing each cell and can be expressed as: but in 'n' dimensional space or real-world scenario where each cell will have value 'x' for each variable, pythagoras's theorem is difficult to work, thus it can be overcome by measuring the distance between points which is stated as: where d xy is the distance between the points x and y which is equal to the sum from the first variable (p = 1) to the last variable (n), of the squares of the distance from each dimension. density was measured to show the spatial availability of healthcare in the study area. it is one of the spatial analyst tools in gis environment for making density analysis of features in a neighbourhood around those features. it is a non-parametric technique generally used to visualize and analyse spatial data for mapping and estimating spatial pattern or event. kernel density calculates both point and line features around each output raster cell which is calculated by considering the total number of the intersection of the individual features. here the raster is calculated by the quadratic formula given by silverman where the highest value is placed at the centre of surface features and pointing towards zero with distance at the search radius [28] . it can be calculated by using the equation: where 'k' is the kernel function with density f(y), 'y' is the sampled data, 'n' is the number of sample and's' is the smoothing parameter or say bandwidth. proximity tool was used to discover spatial association of features. with this tool output information is gained through the buffer and multiple ring buffers which create an areal feature at a specific distance around the input features. multiple buffers were linear for a small number of the foreclosed unit within various distance bands around a given point. present work presented a simple and efficient decisionmaking approach based on a structural and integrated method to deal with the decision-making problem. a novel group of hybrid decision-making framework has been built for evaluating accessible and inaccessible zone to healthcare services by integrating different raster layers i.e. euclidean distance, kernel density, proximity to support the weighted linear combination. weighted linear combination method is a multi-parametric decision model and comes under one of the fundamental classes of multi-criteria evaluation method in gis which follows the compensatory combination rules [29] . this method has been widely used in other studies also, like in land-use suitability analysis [30] , in suitability analysis for soil erosion [29] , diseases susceptibility [31] [32] [33] etc. present work accepted this technique to identify accessible and inaccessible areas for health care by applying equal weight. all selected raster layers were reclassified with equal cell size to combine them into a single accessibility layer. a weighted linear combination is defined as: where wi is the weight value of deciding factor i, pi is the selected raster input and n is the number of selected decision criteria. suitable sites for proposing and allocating new healthcare was determined using suitability analysis. site suitability is a process of allocation of new and ideal sites by analysing exiting site structure, pattern and condition based on several appropriate criteria. for this determination, the present study had prepared a suitable model for understanding appropriate location by integrating different thematic layers like road accessibility, railway network, land use land cover, and residential density. all these maps have been converted into raster so that each pixel can detect a score. it is important in suitability analysis to set a score for each category at 1-5 or 1-9 point scale as per their suitability. thematic maps were combined into composite suitability. for suitability analysis, first of all, land use land cover has been classified. barren, fellow land and low economic and less resourceful land has been considered for highly suitable to allocate new health care. secondly, the rail network and road accessibility have been considered for merging with the above-mentioned land category. areas properly connected through road and rail was taken as a suitable site for such allocation. parallelly, residential accessibility was also taken, 5 km buffer of areas having high population get more preference for suitable sites. this decision approach supported to propose 8 suitable sites for allocating new health care facilities in inaccessible areas. among this which site is best suitable and where argent requires for allocating new health care is determined using topsis analysis. topsis is the acronym of technique for order preference by similarity to ideal solution. this concept was first introduced by hwang and yoon in 1981 [34] . topsis is one of the best multi-criteria decision-making methods used for selecting the best solution from decision criteria. there are adequate studies related to topsis application [35] . using topsis, the ideal and non-ideal solutions are identified simultaneously. in the present study, topsis was used to identify the best site among the proposed suitable sites for health care service. this method is quite simple which is presenting a satisfactory performance in different field of applications. the idea of topsis procedure can be conveyed in a sequence of following steps [36] . step 1 prepare the decision matrix and determine the weight to decision criteria suppose, . . .w a n ) is the weight vector for a-expert or decision-maker, where w a 1 ã¾ w a 2 ã¾ w a 3 ã¾ ã� ã� ã� ã¾ w a n â¼ 1ã� and a = 1, 2, 3, â�¦ n. in a decision matrix, the linguistic term expresses low to excellent range, which has to convert using a 5 point scale in topsis ( table 2) . the selected criteria of the decision making can be: benefit functions (more is a high preference) or non-beneficial (less is a high preference) step 2 calculate the normalised decision matrix ( x ij ). the normalised value x ij is expressed as: step 3 calculate weighted normalised matrix by multiplying its associated weight. the weighted normalised value v ij is expressed as: step 4 calculate the ideal best and ideal worst value where i 0 and i 00 is associated with the ascent and descent factor respectively. the ideal best and worst value is depending on the selected criteria. here, for selecting a suitable site for health care service, the lower distance from the transportation route and the residential area will get the highest preference value and vice versa. step 5 calculate the euclidean distance from the ideal best now, the euclidean distance has to calculate from the ideal best value, s ã¾ j . # 0:5 step 6 calculate the euclidean distance from the ideal worst same as ideal best, the ideal worst value, s ã� j .is as follows # 0:5 step 7 calculate performance score finally, the preference score or relative closeness to the ideal solution is determined. the pi is expressed by: the higher p i the value indicates the best site for allocating propose health care infrastructure. topsis is an efficient technique of multi-criteria decision analysis which emerges as a suitable technique for finding a suitable site and ideal solution. murshidabad district is one of the backward districts in west bengal, where about 2% of india's poor population reside. healthcare accessibility in this district is always a major issue as most of the inhabitants prefer to gain health services due to poor and inefficient access to medical care. the present study aims to explore the suitable site for medical institution after analysing the present situation of healthcare facilities within the district. for the existing situation of health care facilities, the relative accessibility index (rai) was calculated by considering no. of medical institutions, no.of patients admitted in a year, and no.of doctors available per day. the result of the existing situation of health care facility reveals that the spatial distribution is not uniform throughout the district (fig. 2) . hence, for better treatment and getting well service, the resident has to travel another place after crossing a long distance, whereas, many suitable conditions for developing better service have already existed here. the numbers of medical institutions have clustered at the central part of the district i.e. the district capital, behrampore. as a result, the residents of the other areas are suffered to get better facilities. thus, the present study was carried out to find suitable locations for health care service by developing a hybrid decision model. for the same, the decision hierarchy was developed using existing facilities of health service, their spatial distance, density and proximity to support the suitable places; where better and well-accommodated health care service would be proposed by considering the local land use and distance to transportation route. after getting selected the proposed sites for local health care service, these are linked with district medical college and hospital located at the central part using shortest path network analysis. this effort will offer better health service to the residents reside at the peripheral part of the district and interlinked with medical college and hospital. the relative accessibility index (rai) of present health care service was calculated and the result reveals that only behrampore (the capital city of the district) block has good rai, whereas murshidabad-jiaganj and domkal have moderate rai and all others 23 blocks have low to very low rai value. thus, from the overall spatial result of the relative accessibility index, it can be decided that the study area is poor in term of medical facilities and health care services. thus, looking towards this problematic issue, the present study proposed a hybrid decision model with three tiers of analysis to find suitable places for new health care and shortest distance to interlink with the district medical hospital. the first tier of analysis highlighted the distance, density and proximate of each existing health care to find more deprived and inaccessible areas in term of health service. the second tier of analysis emphasized to find suitable sites for proposing new health care services based on land use land cover, distance to road, rail, and proximity to residential areas. finally, the third tier of analysis highlighted the most suitable sites among the proposed health care and network analysis through the shortest path to connect with district medical hospital. figure 3a illustrates the prevailing conditions of health care services including medical college, hospital and nursing home. there are only one medical college and hospital is available. there are some other hospitals and nursing home also available both governmental and public but the spatial equality or homogeneity is not found. figure 3b -d show the distance, density and proximate to present healthcare facilities respectively. the result from each layer of distance, density and proximate reveal that the peripheral parts of the district have always lower facilities. the lower distance to healthcare indicates higher accessibility; lower density of healthcare indicates lower accessibility and closer to healthcare shows higher accessibility. these three spatial layers integrated to consider the accessibility and inaccessibility to healthcare facilities throughout the study area. the 1-5 point scale was used for linear combination i.e. 1 for low accessibility (inaccessibility) and 5 for higher accessibility of healthcare facility. figure 4 shows the overlay result. it depicts the higher and lower spatial accessibility. this result supports the second tier of analysis i.e. to find suitable sites for proposing new healthcare facilities in inaccessible areas. the suitable sites were considered based on four decision factors. these factors were buffered around the road, buffer around rail, land use land cover and buffer around the settlement (fig. 5) . if the suitable sites for healthcare facilities would locate within 5 km, then it would be considered as more suitable than located far from the road because it will offer higher accessibility in term of travel time as well as travel coast. any healthcare that is located nearer to the railway, it will be considered as most accessible because of getting immediate and fast service. land use land cover should be considered before going to choose any space for locating health care. barren land and agricultural fellow nearer to the settlement would be the best site because this site will offer lower land price, utilization of land, and also getting close to residential areas. the sites that are located within 5 km distance to populated areas the maps are produced with the help of data illustrated in table 1 . will get the best service. thus, looking towards these conditions, 8 suitable sites were proposed in the present study which can offer health service in inaccessible areas (fig. 6) . the proposed health care in a suitable site can be merged and interlinked with existing health care to make the district enrich and accessible in term of health service. this is figured in supplementary file (s-1). it is essential to validate the location of each proposed site by verifying ground truth. in the present study, site-1 and site-3 were validated through the ground visit. but the rest sites were not visited; instead, their ground truth was measured in google earth search engine. all sites were selected in open space, barren land or agricultural land, by considering their location nearer to settlement, closer to transportable routes. these ground locations were also plotted in google earth search engine, which is shown in fig. 7 . the technique for order of preference by similarity to ideal solution (topsis) was used to find the ideal best and ideal worst among the proposed sites. the ideal best and the ideal worst value was determined based on the above four decision factors. thus, for considering the most suitable site of health care service keeping transportation service, and nearer to residential areas; the lowest distance has given the highest preference. concomitantly, for land use, the unsuitable land use category has given the lowest preference (table 3 ). the result shows that site-1 has the highest preference score (pi) with 0.81. this site is far from the district medical college and other health care facilities and resides by a huge number of the rural population and therefore, it is the best site to shape modern health care to serve large people surrounding by connecting district medical college and another hospital on a transfer basis (figs. 6, 7) . consequently, site-2 and 7 have the lowest pi with 0.35 and 0.37 respectively. it is because these sites are within 30 km from the district medical college, very close to rail and road transportation route and these sites are considered as already accessible. the other selected suitable sites have high to moderate suitability score depends on their location and health service requirements. finally, the shortest path network analysis was performed to measure the shortest open street distance and get access to reach district medical college and hospital in case of emergency. this task also supports the requirement to construct a new health care service in a suitable site. hence, the far distance from district medical college has the highest require score in comparison to located nearer distance. the shortest path network analysis reveals that site-1 and 5 are located far distance with 64.24 and 47.27 km respectively which indicate more requirements to manage and construct new health care to offer better service to deprived groups of people. in comparison to site-7 and 4 is much closer with 17.92 and 26.28 km correspondingly which indicate not a big issue would arise in case of not building new health care facilities (table 4 ; fig. 8 ). health is an important aspect of human existence as well as social well beings. good service in health can improve the quality of life and progress of a society. but recently, the rapid growth of population and enormous pressure on land, make the service worse. thus, the present study aimed to emphasize healthcare accessibility issues based on service and accommodation available in the study area. the study area, murshidabad district is a backward district of west bengal, india in term of basics infrastructural facilities and amenities [37] . hence, the present study on healthcare accessibility and site suitability are required to highlight previous attempts evidenced that several studies defined accessibility in term of availability, accommodation, affordability, and sometimes acceptability [38] . for example, aday and andersen [39] defined healthcare accessibility based on the availability of health services with special reference to financial, informational, and behavioural influences. unlike, gulliford et al. [40] focused on health demand by highlighting differentiation between having access to healthcare and gaining access to healthcare for overcoming the financial and organizational barriers from health service. all in all, other studies also evidenced common factors for determining healthcare accessibility like (1) spatial distribution of healthcare facilities; (2) transportation facilities and distance to healthcare centres; (3) socio-economic conditions of nearing population group; and (4) accommodation available in healthcare centres [41] . based on these above-mentioned factors; recently, major concerns have been giving on geographic information system (gis) applications in the field of healthcare accessibility due to its efficiency and accuracy in spatial as well as non-spatial analysis [38, 42] . site suitability is another aspect of the healthcare facility, in which major concerns have given towards suitable locations for constructing new healthcare to provide better service to target groups as well as overcome unequal distribution problems of healthcare service. site suitability is based on multi-factor analysis because searching and locating healthcare in suitable places are depended on more than one factor [43] . many studies carried out in the field of site suitability of healthcare using gis and multi-criteria techniques. such as the optimum site selection for a hospital in tehran using a geographical information system [44] ; the suitable site of a regional hospital in taiwan using analytic hierarchy process, sensitivity analysis, and delphi method [45] . but previously it was not attempted to analysis healthcare site suitability by considering accessibility first. poor accessibility needs proposing new healthcare. so, it is essential to analysis accessibility first for proposing and constructing of new healthcare, which is covered in this study. unlike many studies only highlighted healthcare accessibility [39] [40] [41] or site suitability [44, 45] , the present study considered these inter-connected factors by developing a hybrid model. from that point of view, this study is unique and no similar studies ever carried out before. the present study would be useful to health planner in the study area as well as other regions also with similar geographical settings for defining inaccessible areas and locating suitable sites for better health service. while many previous researchers have highlighted the nonspatial data and statistical inference to analyse healthcare accessibility in a geographical location, the present study applied a gis-based hybrid decision-making approach for assessing the spatial accessibility of healthcare facilities and site suitability analysis in murshidabad district of west bengal, india. this study offered a hybrid decision-making approach for proposing suitable sites regarding better healthcare service. to provide better service and reach a deprived group of people, a pipe dream was prepared that needs for logical decision making and resolve existing problems. the result reveals that spatial discrepancy exists in case of access to healthcare facilities. the location of existing healthcare primarily clusters in the central and northern portions. the distance, density and proximate analysis of these healthcares explored the spatial inaccessible areas. to achieve equal access, allocation of new healthcare is essential to reduce the spatial disparity. thus, the equal weight-based weighted linear combination was performed using land use, proximity to road and rail, and distance to residential areas to support suitable site for determining and allocating new healthcare facilities. decision support system with gis integration offered 8 suitable sites in inaccessible areas. poor accessibility and poor health services in an area increase health and social disparities. hence, the urgent requirement is needed to increase accessibility. the present study emphasized the same issue and developed a hybrid approach to integrate b fig. 7 the ground truth areas of proposed healthcare sites after suitability analysis a site-1: considered as best site and urgent require for new healthcare, this site is 1.50 km from rajgram rail station, surrounded by dense rural population and no healthcare facilities nearby, b site-2: very close to nh34 and located in a sparse populated areas, c site-3: far away from nh34, nh60 and railway junction, d site-4: 11.50 km from bhagwangola railway station and located in a densely populated areas, e site-5: very close to ganga river and sagar para road, also located near many densely settlement areas, f site-6: locate at south-west corner of the district and very close to sh7, g site-7: this site is very close to district medical college and hospital, h site-8: just beside sh14, goghata bus stoppage and about 9.0 km from ramel health destination multiple factors to propose sites for new healthcare facilities and remove spatial disparity in the study area. the advantages of developing and using a hybrid model are (1) it integrates different models and approach, (2) it increases the accuracy of the result and reduces the drawbacks of single model and method, (3) it interlinks two or more aspects of a study, for instance, in case of the present study using a hybrid model two aspects, i.e. accessibility to healthcare and site suitability of healthcare have been determined, and (4) hybrid model helps in simplifying the complex relationship of among criteria or perspective. however, a hybrid model also suffers from some disadvantages, like (1) it is more complex to apply (2) the preparation of model take more times than single model (3) sometimes it also suffers from overfitting etc. therefore, removing such disadvantages and adopting the abovementioned advantages, the present proposed and used a hybrid model to show healthcare accessibility and site suitability. this study would appear like a good source of health service enhancement and plan implementation to policymakers and health planners. recently, not only our country but the world worried about the outbreak of 'novel coronavirus'. the government truly finds enormous space for 'isolation' service. globally 2, 193 ,558 confirmed cases are reported (till 17.04.2020). india is no exception in this case, where, 13,495 confirmed cases are identified. it is assumed that murshidabad is also too much vulnerable as there is a lack of basic infrastructure. therefore, in this regards, it is recommended that government and local planners can start medical emergency in proposed sites with primary equipment and service to reach target population groups. on getting success in the mission, modern infrastructural development and service could be proposed afterwards. accessibility analysis of health care facility using geospatial techniques un chief urges greater efforts to improve health and well-being of indigenous peoples human rights and health. world health organisation president's commission for the study of ethical problems in medicine and biomedicine and behavioral science research president's commission delivering quality health services: a global imperative for universal health coverage. geneva: world health organization. licence: cc by-nc-sa 3.0 igo. retrieved on convergence and determinants of health expenditures in oecd countries the determinants of health expenditure: a country-level panel data analysis. geneva: world health organization inequities in access to health services in india: caste, class and region the challenge of building rural health services deprivation, healthcare accessibility and satisfaction: geographical context and scale implications a literature review of the use of gis-based measures of access to health care services measuring geographic access to health care: raster and network-based methods measuring spatial accessibility to primary health care services: utilising dynamic catchment sizes measuring time accessibility and its spatial characteristics in the urban areas of beijing the concept of access: definition and relationship to consumer satisfaction an integrated approach to measuring potential spatial access to health care services accessibility evaluation of land-use and transport strategies: review and research directions measures of spatial accessibility to health care in a gis environment: synthesis and a case study in the chicago region. environment and planning b: planning and design evaluating the accessibility of healthcare facilities using an integrated catchment area approach is there a role for gis in the 'new nhs'? gis and public health accessibility to general practitioners in rural south australia: a case study using geographic information system technology the impact of geographic accessibility on the intensity and quality of depression treatment accessibility and health service utilization for asthma in retrieved from murshidabad district density estimation for statistics and data analysis weighted linear combination method versus grid based overlay operation method-a study for potential soil erosion susceptibility analysis of malda district (west bengal) in india. the egyptian journal of remote sensing and space science integrating geographical information systems and multiple criteria decision making methods using analytic hierarchy process with gis for dengue risk mapping in kolkata municipal corporation spatial susceptibility analysis of vector-borne diseases in kmc using geospatial technique and mcdm approach. modeling earth systems and environment mapping of mosquito-borne diseases in kolkata municipal corporation using gis and ahp based decision making approach application of multi-attribute decision-making methods in swot analysis of mine waste management (case study: sirjan's golgohar iron mine, iran) using hca and topsis approaches in personal digital assistant menu-icon interface design an algorithmic method to extend topsis for decision making problems with interval data appraisal of infrastructural amenities to analyze spatial backwardness of murshidabad district using wsm and gis-based kernel estimation using gis for determining variations in health access in jeddah city, saudi arabia framework for the study of access to medical care what does 'access to health care' mean? literature review of the use of gis-based measures of access to health care services development of a web based gis for health facilities mapping, monitoring and reporting: a case study of the zambian ministry of health hospital site selection using two-stage fuzzy multi-criteria decision making process hospital site selection using fuzzy ahp and its derivatives optimal selection of location for taiwanese hospitals to ensure a competitive advantage by using the analytic hierarchy process and sensitivity analysis publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements we thankfully acknowledge the anonymous three reviewers and the editor in chief for their valuable time, productive comments and suggestions for enlightening the overall quality of our manuscript.funding no fund was received from any sources. conflict of interest on behalf of all authors, the corresponding author states that there is no conflict of interest. key: cord-354491-23cjm86c authors: muller, a. e.; hafstad, e. v.; himmels, j. p. w.; smedslund, g.; flottorp, s.; stensland, s.; stroobants, s.; van de velde, s.; vist, g. e. title: the mental health impact of the covid-19 pandemic onhealthcare workers, and interventions to help them: a rapid systematic review date: 2020-07-04 journal: nan doi: 10.1101/2020.07.03.20145607 sha: doc_id: 354491 cord_uid: 23cjm86c background: the covid-19 pandemic has heavily burdened, and in some cases overwhelmed, healthcare systems throughout the world. healthcare workers are not only at heightened risk of infection, but also of adverse mental health outcomes. identification of organizational, collegial and individual risk and resilience factors impacting the mental health of healthcare workers are needed to inform preparedness planning and sustainable response. methods: we performed a rapid systematic review to identify, assess and summarize available research on the mental health impact of the covid-19 pandemic on healthcare workers. on 11 may 2020, we utilized the norwegian institute of public health's live map of covid-19 evidence, the visualization of a database of 20,738 screened studies, to identify studies for inclusion. we included studies reporting on any type of mental health outcome in any type of healthcare workers during the pandemic. we described interventions reported by the studies, and narratively summarized mental health-related outcomes, as study heterogeneity precluded meta-analysis. we assessed study quality using design-specific instruments. results: we included 59 studies, reporting on a total of 54,707 healthcare workers. the prevalence of general psychological distress across the studies ranged from 7-97% (median 37%), anxiety 9-90% (median 24%), depression 5-51% (median 21%), and sleeping problems 34-65% (median 37%). seven studies reported on implementing mental health interventions, and most focused on individual symptom reduction, but none reported on effects of the interventions. in most studies, healthcare workers reported low interest in and use of professional help, and greater reliance on social support and contact with family and friends. exposure to covid-19 was the most commonly reported correlate of mental health problems, followed by female gender, and worry about infection or about infecting others. social support correlated with less mental health problems. discussion: healthcare workers in a variety of fields, positions, and exposure risks are reporting anxiety, depression, sleep problems, and distress during the covid-19 pandemic, but most studies do not report comparative data on mental health symptoms. before the pandemic. there seems to be a mismatch between risk factors for adverse mental health outcomes among healthcare workers in the current pandemic and their needs and preferences, and the individual psychopathology focus of current interventions. efforts to help healthcare workers sustain healthy relationships to colleagues, family and friends over time may be paramount to safeguard what is already an important source of support during the prolonged crisis. expanding interventions' focus to incorporate organizational, collegial and family factors to support healthcare workers responding to the pandemic could improve acceptability and efficacy of interventions. other: the protocol for this review is available online. no funding was received. healthcare workers in the current pandemic and their needs and preferences, and the individual psychopathology focus of current interventions. efforts to help healthcare workers sustain healthy relationships to colleagues, family and friends over time may be paramount to safeguard what is already an important source of support during the prolonged crisis. expanding interventions' focus to incorporate organizational, collegial and family factors to support healthcare workers responding to the pandemic could improve acceptability and efficacy of interventions. other: the protocol for this review is available online. no funding was received. what is already known on this topic • during viral outbreaks such as covid-19, healthcare providers are at increased risk of infection and negative physical and mental health outcomes • covid-19 is a particular challenge to healthcare systems and workers • healthcare workers' mental health problems correlate with organizational factors such as workload and exposure to covid-19 patients • healthcare workers are more interested in occupational protection, rest, and social support than in professional psychological help • interventions focus more on addressing individual psychopathology, which points towards a mismatch between what workers want and need, and the services available to them needed to save lives and prevent a serious impact on physical and mental health of healthcare workers 3 . previous viral outbreaks have shown that frontline and non-frontline healthcare workers are at increased risk of infection and other adverse physical health outcomes 4 . furthermore, mental health problems putatively associated with healthcare workers' occupational activities were reported during and up until years after epidemics, including symptoms of post-traumatic stress, burnout, depression and anxiety [5] [6] [7] . likewise, reports of the mental toll on healthcare workers have persistently appeared during the current global health crisis [8] [9] [10] . several reviews have already been conducted on healthcare workers' mental health in the covid-19 pandemic, with search dates up to may 2020. pappa et al. 11 identified thirteen studies in a search on 17 april 2020 and pooled prevalence rates; they reported that more than one of every five healthcare workers suffered from anxiety and/or depression; nearly two in five reported insomnia. vindegaard & benros' 12 review, searching on 10 may 2020, identified twenty studies of healthcare workers in a subgroup analysis, and their narrative summary concluded that healthcare workers generally report more anxiety, depression, and sleep problems compared with the general population. in the face of a prolonged crisis such as the pandemic, sustainability of the healthcare response fully relies on its ability to safeguard the health of responders: the healthcare workers 13 ,14 . yet, the recent findings of psychological distress among healthcare workers might indicate that the healthcare system is currently unable to effectively help the helpers. understanding the risks and mental health impact(s) that healthcare workers experience, and identifying possible interventions to address adverse effects, is invaluable. our main aim was to perform a rapid systematic review to identify, assess and summarize available research on the mental health impact of the covid-19 pandemic on healthcare workers and on healthcare workers' understandings of their own mental health during the pandemic. our second aim was to describe the interventions assessed in the literature to prevent or reduce negative mental health impacts on healthcare workers who are at work during the covid-19 pandemic. all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint we conducted a rapid systematic review according to the methods specified in our protocol, published on our institution's website 15 . we included any type of study about any type of healthcare worker during the covid-19 pandemic, with outcomes relating to their mental health. we extracted information about interventions aimed at preventing or reducing negative mental health impacts on healthcare workers. we had no restrictions related to study design, methodological quality, or language. we identified relevant studies by searching the norwegian institute of public health's (niph's) live map of covid-19 evidence (https://www.fhi.no/en/qk/systematic-reviews-hta/map/) and database on 11 may 2020, as described in our protocol 15 . the live map and database contained 20,738 references screened for covid-19 relevance containing primary, secondary, or modelled data. two researchers independently categorized these references according to topic (seven main topics, 52 subordinate topics), population (41 available groups), study design, and publication type. we identified references categorized to the population "healthcare workers", and to the topic "experiences and perceptions, consequences; social, political, economic aspects". in addition, we identified references by searching (title/abstract) in the live map's database, using the keywords: emo*, psych*, stress*, anx*, depr*, mental*, sleep, worry, somatoform, and somatic symptom disorder. we screened all identified references specifically for the inclusion criteria for this systematic review. the protocol of the live map of covid-19 evidence describes the methodology of the map and database 16 . the methodology, including the search, has developed dynamically since march 2020. we performed our first search for the map 12.03.2020 and we have identified references published since 01.12.2019 by searching: • pubmed (national library of medicine), from 01.12.2019 -03.05.2020 • embase (ovid), between 01.12.2019 -27.03.2020 • centers for disease control and prevention (cdc), 01.12.2019 -11.05.2020 all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint the last included search for this review was conducted on 11 may 2020. the search strategy is presented in appendix 1. we developed a data extraction form to collect data on country and setting, participants, exposure to covid-19, intervention if relevant, and outcomes related to mental health. we extracted data on prevalence of mental health problems as well as correlates (i.e. risk/resilience factors); strategies implemented or accessed by healthcare worker to address their own mental health; perceived need and preferences related to interventions aimed at preventing or reducing negative mental health consequences; and experience and understandings of mental health and related interventions. one researcher (aem) extracted data and another checked her extraction. two researchers independently assessed the methodological quality of systematic reviews using the amstar tool 17 and of qualitative studies using the casp checklist 18 . one researcher (aem, sf) assessed the quality of cross-sectional studies using either the jbi prevalence or the jbi cross-sectional analytical checklist, and longitudinal studies using the jibi cohort checklist 19 . results of these checklists are presented in appendix 2 in the standard risk of bias format. we summarized outcomes narratively. for figures without numbers, we extracted numbers using an online software (https://apps.automeris.io/wpd/). we describe interventions and outcomes based on the information provided in the studies. median prevalence rates were presented as box-and-whisker plots. we decided not to perform a quantitative summary of the associations between the various correlates and mental health factors, due to a combination of heterogeneity in assessment measures and lack of control groups, and an overarching lack of descriptions necessary to confirm sufficient homogeneity. our included studies not only varied greatly from one another, they most often did not report sufficient information regarding inclusion criteria, population, setting, and exposure to assess potential clinical heterogeneity. we graded the certainty of the evidence using the grade approach (grading of recommendations assessment, development, and evaluation) 20 . all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint fifty-nine studies were included. table 1 displays their summarized characteristics, while appendix 3 displays characteristics of the individual studies. thirty-nine studies were conducted in or included participants from china; four in iran; three in the usa; two each in france, india, and singapore; and one each from australia, germany, italy, malaysia, and taiwan. two studies reported results of international online surveys; one included respondents from 30 countries and the other from 91 countries. the majority of studies (47) were cross-sectional surveys, four were other cross-sectional designs; two studies reported surveys administered twice over time; three were qualitative studies; and one study searched within a database of existing online surveys. we also identified two systematic reviews 29 ,31 , which identified five primary studies 8 ,35 ,39 ,47 ,76 . the studies reported on healthcare workers working in different settings: 43 studies reported on health care workers in hospitals, two studies were conducted in specialist health services outside hospitals, and three studies in other settings, while 21 studies did not specify the healthcare setting or only partially described multiple settings. no studies reported on nursing homes or primary care settings. in 40 studies, participants were frontline workers, while 26 studies reported on non-frontline workers. frontline or non-frontline activities were unclear in ten studies. six studies reported on interventions to reduce mental health problems. more than half of the studies included nurses (31) and/or doctors (33) . studies reported on a total of 54,707 healthcare workers, ranging from a case study with three participants to a survey of 11,118 participants. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint appendix 2 displays the methodological quality assessments of individual studies. overall assessments are displayed in appendix 3, the description of included studies. twenty-five studies were assessed as having low methodological quality (including eleven of 17 crosssectional studies that provided only prevalence data), twelve medium, and sixteen high. the most common methodological weaknesses across all studies arose from insufficient reporting: samples, settings, and recruitment procedures were often not described thoroughly. while both systematic reviews had low scores on the amstar, all three qualitative studies were assessed on the casp checklist as valuable. four studies had designs that we did not assess for quality: jiang et al. 56 , and schulte et al. 21 six studies reported on the implementation of interventions to prevent or reduce mental health problems caused by the covid-19 pandemic among healthcare workers. these interventions can be loosely divided into those targeting organizational structures, those facilitating team/collegial support, and those addressing individual complaints or strategies. two interventions involved organizational adjustments. the first intervention was reported on by two studies 70 ,72 . hong et al. 70 called it a "comprehensive psychological intervention" for frontline workers undergoing a mandatory two-week quarantine in a vocational resort, following two-to three-week hospital shifts. the quarantine itself was also described as part of the intervention, explicitly intended "to alleviate worries about the health of one's family". other elements included shortened shifts; involvement of the labor union to provide support to healthcare workers' families; and a telephone-based hotline that allowed healthcare workers to speak to trained psychiatrists or psychologists. this hotline had already been available to healthcare workers for four hours per week prior to the pandemic, but was made available for twelve hours, seven days a week. chen et al. 47 reported a second intervention that attempted to address individual complaints and facilitate collegial support. a telephone hotline was set up to provide immediate psychological support, along with a medical team that provided online courses to help healthcare workers handle psychological problems, and group-based activities to release stress. however, uptake was low, and when researchers conducted interviews with the healthcare workers to understand this, healthcare workers reported needing personal protective all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint equipment and rest, not time with a psychologist. they also requested help addressing their patients' psychological distress. in response, the hospital developed more guidance on personal protective equipment, provided a rest space, and provided training on how to address patients' distress. schulte et al. 21 targeted collegial support and building individual strategies through one-hour video "support calls" for healthcare workers called in from their homes, to describe the impact of the pandemic on their lives, to reflect on their strengths, and to brainstorm coping strategies. this intervention was implemented as a response to the hospital redeploying pediatric staff to work as covid-19 frontline staff, and reorganizing pediatric space to accommodate more pediatric and adult covid-19 patients. lv et al. 22 surveyed healthcare workers before and during the outbreak, reporting no further information about the timeline. the study included both those working on the frontline and those with unclear exposure to covid-19. however, it is unclear whether respondents were the same at both time points. the prevalence of anxiety, depression, and insomnia increased over time, all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint whether mild, moderate, moderate to severe, or severe (see figure 2 ). during the outbreak, one out of every four healthcare workers reported at least mild anxiety, depression, or insomnia. even if i try hard, and i've been smoking or drinking a lot lately." the authors presented the changes per item after two weeks, rather than answers at both time points, and the answer scale was not reported. worry worsened for 30% of participants, anxiety for 12%, fidgeting for 9%, fear for 15%, feeling nervous and uneasy for 13%, not thinking one can succeed for 4%, and an increase in smoking and drinking for only 1%. the proportion reporting improvement was similar for fidgeting, fear, and feeling nervous and uneasy, and more improved in not thinking one can succeed and for a reduction in smoking and drinking. two cross-sectional studies reported healthcare workers' self-reported changes in mental health; both were also of low methodological quality due to insufficient reporting. in benham et al. 78 , twelve iranian psychiatry residents were re-deployed to work one frontline shift. half of the residents reported that they experienced more distress after this shift. abdessater et al. 28 was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint studied 275 urology residents not working on the frontline. when asked to report the level of stress caused by covid-19, 56% reported a medium to high amount of stress, and the remaining reported none to low. less than 1% had initiated a psychiatric treatment during the pandemic. a third cross-sectional study 64 , also of low methodological quality, surveyed 60 healthcare workers in china in february, during the "outbreak period". a different cohort of 60 healthcare workers were surveyed in march, during the "non-epidemic outbreak period". the healthcare workers in to the second phase of the survey reported less symptoms of anxiety and depression, and higher health-related quality of life. twenty-nine studies reported prevalence data of mental health variables as proportions or percentages. (seventeen additional studies reported data as average scores on various instruments, and we did not extract this data.) we present box-and-whisker plots in figure 3 to show the distribution of anxiety, depression, distress, and sleeping problems among the healthcare workers investigated in the 29 studies, using the authors' own methods of assessing these outcomes for anxiety, there were data from 22 studies. the percentage of healthcare workers with anxiety ranged from 9-90% with a median of 24%. for depression, there were data from 19 studies. the percentage with depression ranged from 5-51%, with a median of 21%. for sleep problems, there were data from six studies. the percentage with sleeping problems ranged from 34-65%, with a median of 37%. for distress, there were data from 13 studies. the percentage with distress ranged from 7-97%, with a median of 37%. only one study 65 reported prevalence of somatic symptoms, including decreased appetite or indigestion (59%) and fatigue (55%). all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. t a b l e 2 : s u m m a r y o f f i n d i n g s t a b l e p a t i e n t o r p o p u l a t i o n : h e a l t h c a r e w o r k e r s , b o t h f r o n t l i n e a n d n o n -f r o n t l i n e s e t t i n g : c h i n a ( 1 9 s t u d i e s ) . g e r m a n y ( 1 s t u d y ) , i n d i a ( 1 s t u d y ) , s i n g a p o r e ( 1 s t u d y ) , f r a n c e ( 1 s t u d y ) , i r a n ( was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint the most commonly reported protective factor associated with reduced risk of mental health problems was having social support 35 ,49 ,53 ,74 . two studies directly measured self-perceived resilience. bohlken et al. 38 asked their sample of psychiatrists and neurologists to assess how resilient they were on a likert scale from 1-5 ("not applicable" to "completely applicable"), and 86% selected the two highest categories. cai et al. 34 compared experienced frontline workers with inexperienced frontline workers, and found that inexperienced workers scored lower on total resilience on the connor-david resilience scale as well as within each of three subscales, and had more mental health symptoms. inexperienced workers were also younger and had less social support available to them. ten studies reported that healthcare workers utilized other resources or had individual strategies to address their own mental health during the pandemic, separate from formal interventions. six studies reported healthcare workers' utilized support from family/friends during the pandemic. "family" was the most common stress coping mechanism utilized by louie et al. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. kang et al. 43 found slightly higher levels of interest in professional resources. when asked from whom they prefer to receive "psychological care" or "resources", 40% answered psychologists or psychiatrists, 14% answered family or relatives, 15% answered friends or colleagues, 2% answered others, and 30% said they did not need help. the authors found that preferred sources of psychological resources were related to the level of psychological distress. in a structural equation model that uncovered clusters of healthcare workers with different distress all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint levels (subthreshold, mild, moderate, and severe), those with moderate and severe distress more often preferred to receive care from psychologists or psychiatrists, while those with subthreshold and mild distress more often preferred to seek care from family or relatives. in two studies, participants specified that they had a greater need for personal protective equipment than for psychological help. chung et al. 69 reported this in a survey that allowed healthcare workers to describe their needs and concerns in free text and to request contact with a psychiatric nurse. while 3% requested such contact, nearly half of those who answered the free text question about their psychiatric needs wrote that they needed personal protective equpiment instead, and 20% said they were worried about infection. chen et al.'s 47 study was to understand why uptake of their psychological intervention was so low, and findings were identical to chung et al.'s: "many staff mentioned that they did not need a psychologist, but needed more rest without interruption and enough protective supplies" (p. e15). only one study explored how healthcare workers would be willing to provide mental health services to other healthcare workers: twelve psychiatry residents were re-deployed as frontline workers for one shift in benham et al.'s 78 study. after that shift, none were willing to provide face-to-face mental health services to other healthcare workers, although 75% said they would provide online services. they identified healthcare workers of deceased patients as possible target populations for online services. three qualitative studies assessed as valuable were included. two interconnected themes across all three studies were distress stemming both from concern for infecting family members, and from being aware of family members' concern for the healthcare workers. wu et al. 71 explored reasons for stress during interviews with healthcare workers at a psychiatric hospital. while these healthcare workers were not on the frontline, they felt they were at higher risk of exposure than healthcare workers at a general hospital. their wards were crowded, and several patients were admitted from emergency rooms with aggressive behaviors that made social distancing difficult or that posed direct challenges to healthcare workers' use of personal protective equipment (such as tearing masks). healthcare workers felt unprepared because all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint psychiatric hospitals had no plans in place. at the same time, they also felt that their peers on the frontline were providing more valuable care. an additional source of stress was knowledge of their own risk of infection and transmission to family members, particular to elderly parents in their care, and to children who were at home and whose schoolwork had to additionally be managed. the disruption of the pandemic to nurses' personal lives and career plans was another stressor. sun et al. 67 interviewed twenty frontline nurses about their psychological experiences of frontline work. similar themes as wu et al.'s sources of stress were reported, particularly the fear of infecting friends and family. elderly parents and children at home were again mentioned, and concern was great enough that several respondents did not tell their family they were working on the frontline, while others did not live at home during this period. as with wu et al.'s nonfrontline workers, these healthcare workers also reported fear and anxiety of a new infectious disease that they felt unprepared to handle on a hospital-level, unprepared to treat on a patientlevel, and from which they were unable to protect themselves. the first week of training and the first week of actual frontline work was characterized by these negative emotions, which were then joined -not necessarily replaced -by more positive emotions such as pride at being a frontline nurse, confidence in the hospital's capacity, and recognition by the hospital. yin et al. 73 used a framework of existence, relatedness, and growth theory to analyze nurses' psychological needs. they reported nurses' identification of existence needs as primarily health and security: their own physical and mental health, personal protective equipment, and emotional stability for their family. their need for relatedness was represented by needs for relationships and affection, as well as for care, help, and support from colleagues and bosses, as well as from outside the hospital. finally, growth needs referred to needing knowledge of covid-19 infection prevention and control, particularly from the authorities. motivation, as could emotional support. affecting them negatively were fears of infecting their families, particularly because their families would suffer more financially from needing to be quarantined than they already were suffering under the lockdown; fears of using personal protective equipment incorrectly; and feeling unequipped to handle patients' non-medical needs. healthcare workers reported that stigma suppressed patients' provision of accurate travel and all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint quarantine history. this was an issue they were ill-equipped to help patients address when they returned to the community. healthcare workers also reported that they were stigmatized, because they were potential sources of infection. this systematic review identified 59 heterogeneous studies that examined the mental health of healthcare workers during the covid-19 pandemic. the total of 54,707 participants included mainly frontline nurses and physicians, but also other healthcare workers who provided clinical care, administration, or other clinical tasks. studies reported a variety of outcomes and situations, including the implementation of interventions to prevent or reduce mental health problems, other resources and strategies utilized by healthcare workers, and on healthcare workers' mental health responses to re-deployment as frontline workers. while the majority of studies were cross-sectional and assessed as having high risk of bias, several patterns in their findings were evident: more healthcare workers were interested in social support to alieve mental health impacts, only a minority were interested in professional help for these problems, and yet interventions described in the literature largely seemed to focus on relieving individual symptoms. the current study reveals a mismatch between the likely organizational sources of psychological distress, such as workload and lack of personal protective equipment, and how healthcare systems are attempting to relieve distress at an individual level. between one and two of every five healthcare worker reported anxiety, depression, distress, and/or sleep problems. only one study reported on somatic symptoms such as changes in appetite. these findings comport with much of the existing literature; healthcare workers in general, and particularly intensive care nurses and physicians, are known for elevated levels of distress compared to the general population [79] [80] [81] [82] [83] . findings from the two studies following healthcare worker over two timepoints during the pandemic indicate that these complaints increased from the first timepoint to the next. thus, there is reason to believe that the pandemic and working conditions during the pandemic negatively affects healthcare workers, although more longitudinal studies are needed to confirm this hypothesis. all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. research may hinder the discovery of underlying organizational faults, which could be more appropriate targets of intervention. this focus on the individual rather than system-level factors is also common in interventions for healthcare worker burn-out before the pandemic 86 . the most striking illustration of this was the finding shared by two studies 47 ,69 that healthcare workers said personal protective equipment would benefit their mental health more than professional help. on the other hand, it is possible that healthcare workers could benefit from professional mental health interventions more than they recognize or report, and that under-recognition is related to occupational culture, fear of stigma or weakness, or simply cultural differences, as the two studies in question both reported on chinese healthcare workers. the possible risk and protective/resilience factors reported by our included studies are similar to those identified in other recent reviews of healthcare workers' mental health during other novel all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint viral outbreaks such as sars, mers, ebola, and h1n1. these factors, not related to individual psychopathology, could be areas for healthcare settings to proactively address: junior status, higher exposure, longer quarantine time, having an infected family member, lack of practical support, stigma, and younger age were risk factors of distress in kisely et al's 87 pandemic. our quality assessment of qualitative and quantitative studies should help other researchers in the evidence synthesis process, if they wish to use methodological quality in their inclusion criteria. we followed the norwegian institute of public health's rigorous methodological standards for systematic reviews, such as two researchers screening and assessing eligibility. an additional methodological strength is our utilization of the live map of covid-19 evidence, one of the first reviews to do so (see also two reports 89 ,90 and one diagnostic accuracy study 91 . by using our map, we quickly identified 871 studies that had already been categorized to our topic and population of interest, without having to search in academic databases and screen again. while not being able to conduct a meta-analysis is unfortunate, it was appropriate not to assume that poorly reported studies were homogenous enough. the principle of homogeneity tends to be overlooked by systematic reviewers eager to produce a summary estimate, but if all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint met, means that all studies included were similar enough that their participants can be considered participants of one large study 92 . the result, however, is that the prevalence data about mental health problems does not provide a summary estimate that can be generalized. other weaknesses are those common to rapid reviews due to time pressure, such as fewer details about the included studies' populations being presented than normally reported. the covid-19 pandemic has resulted in a flood of studies, many of which have been pushed through the peer-review process and published at speeds hitherto unseen (see glasziou 93 for a discussion). it is therefore not surprising that the majority of our included 59 studies were assessed as having a high risk of bias or being of low methodological quality. lack of information on samples or procedures was a common limitation, leading to serious implications to the generalizability and validity of findings. we also call on journals and researchers to balance the need for rapid publication with properly conducted studies, reviews and guidelines 94 . healthcare workers in a variety of fields, positions, and exposure risks are reporting anxiety, depression, distress, and sleep problems during the covid-19 pandemic. causes vary, but for those on the frontline in particular, a lack of opportunity to adequately rest and sleep is likely related to extremely high burdens of work, and a lack of personal protective equipment or training may exacerbate mental health impacts. provision of appropriate personal protective equipment and work rotation schedules to enable adequate rest in the face of long-lasting disasters such as the covid-19 pandemic seem paramount. over time, many more healthcare workers may struggle with mental health and somatic complaints. the six studies exploring mental health interventions mainly focused on individual approaches, most often requiring healthcare workers to initiate contact. proactive organizational approaches could be less stigmatizing and more effective, and generating evidence on the efficacy of interventions/strategies of either nature is needed. as the design of most studies was poor, reflecting the urgency of the pandemic, there is also a need to incorporate high-quality research in disaster preparedness planning. all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint gev conceived of this review and conducted the grade assessments. ss and søs wrote the first drafts of the introduction and discussion. aem identified the studies within the map for this review. jpwh and evh wrote the first draft of the methods. aem, sv, gs, gev, sf, evh, and jpwh developed the methods of the live map of covid-19 evidence. søs contributed to identifying outcomes. aem, sf, and gev extracted data and assessed study quality. aem and gs conducted the analyses. all authors contributed to the protocol and design of this review. all authors have read and approved the final draft of this manuscript. the corresponding author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive license (or non exclusive for government employees) on a worldwide basis to the bmj publishing group ltd to permit this article (if accepted) to be published in bmj editions and any other bmjpgl products and sublicenses such use and exploit all subsidiary rights, as set out in our license. competing interest: all authors have completed the unified competing interest form (available on request from the corresponding author) and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. transparency: the lead author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained. funding: no funding was received. ethical approval: no ethical approval was required for this systematic review. patient and public involvement: this rapid systematic review did not seek involvement of the population of interest (healthcare providers) due to time constraints. healthcare providers will instead receive direct dissemination of results. all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted july 4, 2020. . https://doi.org/10.1101/2020.07.03.20145607 doi: medrxiv preprint the italian health system and the covid-19 challenge critical care crisis and some recommendations during the covid-19 epidemic in china covid 19 public health emergency of international concern (pheic) global research and innovation forum: towards a research roadmap mers and covid-19 among healthcare workers: a narrative review prevalence of psychiatric disorders among toronto hospital workers one to two years after the sars outbreak long-term psychological and occupational effects of providing hospital healthcare during sars outbreak mental health of nurses working at a governmentdesignated hospital during a mers-cov outbreak: a cross-sectional study mental health survey of 230 medical staff in a tertiary infectious disease hospital for covid-19 covid-19 pandemic and its impact on mental health of healthcare professionals the experiences of health-care providers during the covid-19 crisis in china: a qualitative study prevalence of depression, anxiety, and insomnia among healthcare workers during the covid-19 pandemic: a systematic review and meta-analysis covid-19 pandemic and mental health consequences: systematic review of the current evidence covid-19 and italy: what next? protect our healthcare workers no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted the impact of the covid-19 pandemic on mental health of health care workers: protocol for a rapid systematic review a systematic and living evidence map on covid-19 amstar 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both casp checklist for qualitative research grade guidelines: 1. introduction-grade evidence profiles and summary of findings tables addressing faculty emotional responses during the covid19 pandemic anxiety and depression survey of chinese medical staff before and during covid-19 defense assessment of iranian nurses′ knowledge and anxiety toward covid-19 during the current outbreak in iran assessment of the mental health of front line healthcare workers in a covid-19 epidemic epicenter of china at the height of the storm: healthcare staff's health conditions and job satisfaction and their associated predictors during the epidemic peak of covid-19 brief psychotic disorder triggered by fear of coronavirus? comparison of the indicators of psychological stress in the population of hubei province and non-endemic provinces in china during two weeks during the coronavirus disease 2019 (covid-19) outbreak in february 2020 covid19 pandemic impacts on anxiety of french urologist in training: outcomes from a national survey covid-19 and mental health: a review of the existing literature covid-19 and paediatric health services: a survey of paediatric physicians in australia and new zealand covid-19 associated psychiatric symptoms in healthcare workers: viewpoint from internal medicine and psychiatry residents covid-19 outbreak situation and its psychological impact among surgeon in training in france covid-19-related information sources and psychological well-being: an online survey study in taiwan a cross-sectional study on mental health among health care workers during the outbreak of corona virus disease 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 emergency responses to covid-19 outbreak: experiences and lessons from a general hospital in nanjing evaluation of the level of anxiety among iranian multiple sclerosis fellowships during the outbreak of covid-19 factors associated with mental health outcomes among health care workers exposed to coronavirus disease fear and practice modifications among dentists to combat novel coronavirus disease (covid-19) outbreak the immediate mental health impacts of the covid-19 pandemic among people with or without quarantine managements the impact of covid-19 pandemic on spine surgeons worldwide impact on mental health and perceptions of psychological care among medical and nursing staff in wuhan during the 2019 novel coronavirus disease outbreak: a cross-sectional study investigation and analysis of the psychological status of the clinical nurses in a class a hospital facing the novel coronavirus pneumonia issues relevant to mental health promotion in frontline health care providers managing quarantined/isolated covid19 patients mental health and psychosocial problems of medical health workers during the covid-19 epidemic in china mental health care for medical staff in china during the covid-19 outbreak. the lancet psychiatry mental health status of doctors and nurses during covid-19 epidemic in china mental health, risk factors, and social media use during the covid-19 epidemic and cordon sanitaire among the community and health professionals in wuhan multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid-19 outbreak novel coronavirus and related public health interventions are negatively impacting mental health services online mental health services in china during the covid-19 outbreak. the lancet psychiatry perceived social support and its impact on psychological status and quality of life of medical staffs after outbreak of sars-cov-2 pneumonia: a cross-sectional study prevalence and influencing factors of anxiety and depression symptoms in the first-line medical staff fighting against the covid-19 in gansu prevalence of self-reported depression and anxiety among pediatric medical staff members during the covid-19 outbreak in guiyang, china psychological crisis intervention during the outbreak period of new coronavirus pneumonia from experience in shanghai psychological effects of covid-19 on hospital staff: a national cross-sectional survey of china mainland psychological impact and coping strategies of frontline medical staff in hunan between psychological impact and predisposing factors of the coronavirus disease 2019 (covid-19) pandemic on general public in china psychological impact of the covid-19 pandemic on adults and their children in italy psychological impact of the covid-19 pandemic on health care workers in singapore psychological impact on women health workers involved in covid-19 outbreak in wuhan: a cross-sectional study psychological status of medical workforce during the covid-19 pandemic: a cross-sectional study psychological status of surgical staff during the covid-19 outbreak psychological stress of icu nurses in the time of covid-19 psychological stress of medical staffs during outbreak of covid-19 and adjustment strategy a qualitative study on the psychological experience of caregivers of covid-19 patients screening for chinese medical staff mental health by sds and sas during the outbreak of covid-19 staff mental health self-assessment during the covid-19 the stress and psychological impact of the covid-19 outbreak on medical workers at the fever clinic of a tertiary general hospital in beijing: a cross-sectional study stressors of nurses in psychiatric hospitals during the covid-19 outbreak a study of basic needs and psychological wellbeing of medical workers in the fever clinic of a tertiary general hospital in beijing during the covid-19 outbreak a study on the psychological needs of nurses caring for patients with coronavirus disease 2019 from the perspective of the existence, relatedness, and growth theory survey of insomnia and related social psychological factors among medical staffs involved with the 2019 novel coronavirus disease outbreak symptom cluster of icu nurses treating covid-19 pneumonia patients in wuhan vicarious traumatization in the general public, members, and nonmembers of medical teams aiding in covid-19 control work stress among chinese nurses to support wuhan for fighting against the covid-19 epidemic working in the emergency and inpatient covid-19 special wards: a different experience for iranian psychiatric trainees amid the outbreak: running title: experience of iranian psychiatric trainees in covid-19 special wards psychosocial work environment and mental health--a meta-analytic review prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis dysfunctional psychological responses among intensive care unit nurses: a systematic review of the literature %j revista da escola de enfermagem da usp the sleep-deprived human brain job decision latitude, job demands, and cardiovascular disease: a prospective study of swedish men health workforce burn-out occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis factors affecting mental health of health care workers during coronavirus disease outbreaks: a rapid systematic review should healthcare personnel in nursing homes without respiratory symptoms wear facemasks for primary prevention of covid-19? -a rapid review social and economic vulnerable groups during the covid-19 pandemic antibody tests for identification of current and past infection with sars-cov-2 mixed and indirect treatment comparisons. evidence synthesis for decision making in healthcare waste in covid-19 research using grade in situations of emergencies and urgencies: certainty in evidence and recommendations matters during the covid-19 pandemic, now more than ever and no matter what key: cord-319828-9ru9lh0c authors: shi, shuyun; he, debiao; li, li; kumar, neeraj; khan, muhammad khurram; choo, kim-kwang raymond title: applications of blockchain in ensuring the security and privacy of electronic health record systems: a survey date: 2020-07-15 journal: comput secur doi: 10.1016/j.cose.2020.101966 sha: doc_id: 319828 cord_uid: 9ru9lh0c due to the popularity of blockchain, there have been many proposed applications of blockchain in the healthcare sector, such as electronic health record (ehr) systems. therefore, in this paper we perform a systematic literature review of blockchain approaches designed for ehr systems, focusing only on the security and privacy aspects. as part of the review, we introduce relevant background knowledge relating to both ehr systems and blockchain, prior to investigating the (potential) applications of blockchain in ehr systems. we also identify a number of research challenges and opportunities. there is an increasing interest in digitalizing healthcare systems by governments and related industry sectors, partly evidenced by various initiatives taking place in different countries and sectors. for example, the then u.s. president signed into law the health information technology for economic and clinical health (hitech) act of 2009, as 5 part of the american recovery and reinvestment act of 2009. hitech is designed to encourage broader adoption of electronic health records (ehrs), with the ultimate aim of benefiting patients and society. the potential benefits associated with ehr systems (e.g. public healthcare management, online patient access, and patients medical data sharing) have also attracted the interest of the research community [1, 2, 3, 4, 5, 6, 7, 8, 9] . the 10 potential of ehrs is also evidenced by the recent 2019 novel coronavirus (also referred to as 2019-ncov and covid-2019) pandemic, where remote patient monitoring and other healthcare deliveries are increasingly used in order to contain the situation. as with any maturing consumer technologies, there are a number of research and operational challenges. for example, many existing ehr systems use a centralized server 15 model, and hence such deployments inherit security and privacy limitations associated with the centralized server model (e.g. single point of failure and performance bottleneck). in addition, as ehr systems become more commonplace and the increasing understanding of the importance of data (particularly healthcare data), honest but curious servers may surreptitiously collect personal information of users while carrying out 20 their normal activities. in recent times, there is an increasing trend in deploying blockchain in a broad range of applications, including healthcare (e.g. public healthcare management, counterfeit drug prevention, and clinical trial) [10, 11, 12 ]. this is not surprising, since blockchain is an immutable, transparent and decentralized distributed database [13] that can be 25 leveraged to provide a secure and trusty value chain. an architecture of blockchain-based healthcare systems is shown in fig. 1 . blockchain is a distributed ledger database on a peer-to-peer (p2p) network that comprises a list of ordered blocks chronologically. in other words, this is a decentralized and trustworthy distributed system (without relying on any third party). trust relation among 30 distributed nodes is established by mathematical methods and cryptography technologies instead of semi-trusted central institutions. blockchain-based systems can mitigate the limitation of the single point of failure. besides, since data is recorded in the public ledger, and all of nodes in the blockchain network have ledger backups and can access these data anytime and anywhere, such a system ensures data transparency and helps to 35 build trust among distributed nodes. it also facilitates data audit and accountability by having the capability to trace tamper-resistant historical record in the ledger. depending on the actual deployment, data in the ledger can be stored in the encrypted form using different cryptographic techniques; hence, preserving data privacy. users can also protect their real identities in the sense of pseudo-anonymity. to enhance robustness, 40 we can introduce smart contracts (i.e. a kind of self-executing program deployed on the distributed blockchain network) to support diverse functions for different application scenarios. specifically, the terms of smart contract can be preset by users and the smart contract will only be executed if the terms are fulfilled. hence, this hands over control to the owner of the data. there are a (small) number of real-world blockchain-based 45 healthcare systems, such as gem, guardtime and healthbank [14] . hence, in this paper we focus on blockchain-based healthcare systems. specifically, we will comprehensively review some existing work, and identify existing and emerging challenges and potential research opportunities. prior to presenting the results of our re-3 view, we will first introduce ehr system and blockchain architecture in the next section. 50 then, in section 3, we will review the extant literature and provide a comparative summary of some existing systems. in section 4, we identify a number of potential research opportunities. finally, we conclude the paper in the last section. in a centralized architecture, such as those that underpin a conventional ehr system, 55 a central institution is tasked with managing, coordinating and controlling of the entire network. however, in a distributed architecture, all nodes are maintained without relying on a central authority. now, we will briefly explain the ehr system and blockchain technology. the electronic health record (ehr) is generally defined to be the collection of patients' electronic health information (e.g. in the form of electronic medical records -emrs). emrs can serve as a data source for ehr mainly from healthcare providers in the medical institutions. the personal health record (phr) contains personal healthcare information, such as those obtained from wearable devices owned and controlled by 65 patients. information collected as part of phrs can be available to healthcare providers, by users (patients). in theory, ehr systems should ensure the confidentiality, integrity and availability of the stored data, and data can be shared securely among authorized users (e.g. medical practitioners with the right need to access particular patient's data to facilitate diagno-70 sis). in addition, such a system if implemented well, can reduce data replication and the risk of lost record, and so on. however, the challenge of securing data in such systems, whether in-transit or at-rest, is compounded by the increasing connectivity to these systems (e.g. more potential attack vectors). for example, mobile devices that can sync with the ehr system is a potential attack vector that can be targeted (e.g. an attacker 75 can seek to exploit a known vulnerability in the hospital-issued mobile devices and install malware to facilitate covert exfiltration of sensitive data (e.g. phrs)). one of the key benefits of ehr systems is the availability of large volumes of data, which can be used to facilitate data analysis and machine learning, for example to inform other medical research efforts such as disease forecasting (e.g. the 2019 novel 80 coronavirus). furthermore, wearable and other internet of things (iot) devices can collect and upload relevant information, including those relating to phrs, to the ehr systems, which can facilitate healthcare monitoring and personalized health services. blockchain is made popular by the success of bitcoin [15] , and can be used to facilitate 85 trustworthy and secure transactions across an untrusted network without relying on any centralized third party. we will now introduce the fundamental building blocks in the blockchain [16, 17, 18] . blockchain is a chronological sequence of blocks including a list of complete and valid transaction record. blocks are linked to the previous block by a reference (hash value), 90 and thus forming a chain. the block preceding a given block is called its parent block, and the first block is known as the genesis block. a block [15] consists of the block header the block header contains: • block version: block validation rules; 95 • previous block hash: hash value of the previous block; • timestamp: the creation time of the current block; • nonce: a 4-byte random field that miners adjust for every hash calculation to solve a pow mining puzzle (see also section 2.2.2); • body root hash: hash value of the merkle tree root built by transactions in the 100 block body; • target hash: target threshold of hash value of a new valid block. the target hash is used to determine the difficulty of the pow puzzle (see also section 2.2.2). merkle tree is used to store all the valid transactions, in which every leaf node is a 105 transaction and every non-leaf node is the hash value of its two concatenated child nodes. such a tree structure is efficient for the verification of the transaction's existence and integrity, since any node can confirm the validation of any transaction by the hash value of the corresponding branches rather than entire merkle tree. meanwhile, any modification on the transaction will generate a new hash value in the upper layer and 110 this will result in a falsified root hash. besides, the maximum number of transactions that a block can contain depends on the size of each transaction and the block size. these blocks are then chained together using cryptographic hash function in an append-only structure. that means new data is only appended in the form of additional blocks chained with previous blocks since altering and deleting previously confirmed data 115 is impossible. as previously discussed, any modification of one of the blocks will generate a different hash value and different link relation. hence, achieving immutability and security. digital signature based on asymmetric cryptography is generally used for transaction 120 authentication in an untrustworthy environment [19, 20] . blockchain uses asymmetric 6 cryptography mechanism to send transactions and verify the authentication of transacotherwise, it will be discarded in this process. only valid transactions can be stored in the new block of blockchain network. we will take the coin transfer as an example (see fig. 3 ). alice transfers a certain amount of coins to bob. in step 1, she initiates a transaction signed by her private key. the transaction can be easily verified by others using alice's public key. in step 2, the 135 transaction is broadcasted to other nodes through the p2p network. in step 3, each node will verify the transaction by predefined rules. in step 4, each validated transaction will be packed chronologically and appended to a new block once a miner solves the puzzle. finally, every node will update and back up the new block. in the blockchain network, there is no trusted central authority. thus, reaching a consensus for these transactions among untrustworthy nodes in a distributed network is an important issue, which is a transformation of the byzantine generals (bg) problem proposed in [22] . the bg problem is that a group of generals command the byzantine army to circle the city, and they have no chance of winning the war unless all of them 145 attack at the same time. however, they are not sure whether there are traitors who might retreat in a distributed environment. thus, they have to reach an agreement to attack or retreat. it is the same challenge for the blockchain network. a number of protocols have been designed to reach consensus among all the distributed nodes before a new block is linked into blockchain [23] , such as the following: • pow (proof of work) is the consensus mechanism used in bitcoin. if the miner node who has certain computing (hashing) power wishes to obtain some rewards, the miner must perform the laborious task of mining to prove that he is not malicious. the task requires that the node repeatedly performs hash computations to find an eligible nonce value that satisfies the requirement that a hashed block 155 head must be less than (or equal to) the target hash value. the nonce is difficult to generate but easy for other nodes to validate. the task is costly (in terms of computing resources) due to the number of difficult calculations. a 51% attack is a potential attack in the blockchain network, where if a miner or a group of miners can control more than 51% of the computing power, they could interfere with the 160 generation of new blocks and create fraudulent transaction records beneficial for the attackers. • pos (proof of stake) is an improved and energy-saving mechanism of pow. it is believed that nodes with the largest number of stakes (e.g. currency) would be less likely to attack the network. however, the selection based on account balance is 165 unfair because the richest node is more likely to be dominant in the network, which would be similar to a centralized system gradually. blockchain systems are divided into three types based on permissions given to network 210 nodes: • public blockchain. the public blockchain is open to anyone who wants to join anytime and acts as a simple node or as a miner for economic rewards. bitcoin [15] and ethereum [25] are two well-known public blockchain platforms. • private blockchain. the private blockchain network works based on access control, 215 in which participants must obtain an invitation or permissions to join. gemos [26] and multichain [27] are both typical private blockchain platforms. • consortium blockchain. the consortium blockchain is "semi-private" sitting on the fence between public and private blockchains. it is granted to a group of approved organizations commonly associated with enterprise use to improve business. hy-220 perledger fabric [28] is a business consortium blockchain framework. ethereum also supports for building consortium blockchains. generally, ehrs mainly contain patient medical history, personal statistics (e.g. age and weight), laboratory test results and so on. hence, it is crucial to ensure the security 225 and privacy of these data. in addition, hospitals in countries such as u.s. are subject to exacting regulatory oversight. there are also a number of challenges in deploying and implementing healthcare systems in practice. for example, centralized server models are vulnerable to the single-point attack limitations and malicious insider attacks, as previously discussed. users (e.g. patients) whose data is outsourced or stored in these 230 ehr systems generally lose control of their data, and have no way of knowing who is accessing their data and for what kind of purposes (i.e. violation of personal privacy). such information may also be at risk of being leaked by malicious insiders to another organization, for example an insurance company may deny insurance coverage to the particular patient based on leaked medical history. meanwhile, data sharing is increasingly crucial particularly as our society and population become more mobile. by leveraging the interconnectivity between different healthcare entities, shared data can improve medical service delivery, and so on. overcoming the "information and resource island" (information silo) will be challenging, for example due to privacy concerns and regulations. the information silo also contributes to 240 unnecessary data redundancy and red-tape. in this case, the health insurance portability and accountability act (hipaa) was • unique identifiers rule. only the national provider identifier (npi) identifies covered entities in the standard transactions to protect the patient identity information. • enforcement rule. investigation and penalties for violating hipaa rules. there is another common framework for audit trails for ehrs, called iso 27789, to keep personal health information auditable across systems and domains. secure audit record must be created each time any operation is triggered via the system complying with iso 27789. hence, we posit the importance of a collaborative and transparent data 260 sharing system, which also facilitates audit and post-incident investigation or forensics in the event of an alleged misconduct (e.g. data leakage). such a notion (forensic-by-design) is also emphasized by forensic researchers [29, 30] . as a regulatory response to security concerns about managing the distribution, storage and retrieval of health record by medical industry, title 21 cfr part 11 places 265 requirements on medical systems, including measures such as document encryption and the use of digital signature standards to ensure the authenticity, integrity and confidentiality of record. we summarize the following requirements that should be met based on these relevant standards above when implementing the next generation secure ehr systems: • accuracy and integrity of data (e.g. any unauthorized modification of data is not allowed, and can be detected); • security and privacy of data; • efficient data sharing mechanism (e.g. [31] ); • mechanism to return the control of ehrs back to the patients (e.g. patients can 275 monitor their record and receive notification for loss or unauthorized acquisition); • audit and accountability of data (e.g. forensic-by-design [29, 30] ). the above properties can be achieved using blockchain, as explained below: • decentralization. compared with the centralized mode, blockchain no longer needs to rely on the semi-trusted third party. • security. it is resilient to single point of failure and insider attacks in the blockchainbased decentralized system. • pseudonymity. each node is bound with a public pseudonymous address to protect its real identity. • immutability. it is computationally hard to delete or modify any record of any 285 block included in the blockchain by one-way cryptographic hash function. • autonomy. patients hold the rights of their own data and share their data flexibly by the settings of special items in the smart contract. • incentive mechanism. incentive mechanism of blockchain can stimulate the cooperation and sharing of competitive institutions to promote the development of 290 medical services and research. • auditability. it is easy to keep trace of any operation since any historical transaction is recorded in the blockchain. hence, if blockchain is applied correctly in the ehr systems, it can help to ensure the security of ehr systems, enhance the integrity and privacy of data, encourage orga-295 nizations and individuals to share data, and facilitate both audit and accountability. based on the requirements of a new version of secure ehr systems and the characteristics of blockchain discussed in the preceding section 2.3, we will now describe the key goals in the implementation of secure blockchain-based ehr systems as follows: • privacy: individual data will be used privately and only authorized parties can access the requested data. • security: in the sense of confidentiality, integrity and availability (cia): 1. confidentiality: only authorized users can access the data. integrity: data must be accurate in transit and not be altered by unauthorized 305 entity(ies). 3. availability: legitimate user's access to information and resources is not improperly denied. • accountability: an individual or an organization will be audited and be responsible for misbehavior. • authenticity: capability to validate the identities of requestors before allowing access to sensitive data. • anonymity: entities have no visible identifier for privacy. complete anonymity is challenging, and pseudo-anonymity is more common (i.e. users are identified by something other than their actual identities). in order to satisfy the above goals, existing blockchain-based research in the healthcare domain includes the following main aspects: • data storage. blockchain serves as a trusted ledger database to store a broad range of private healthcare data. data privacy should be guaranteed when secure storage is achieved. however, healthcare data volume tends to be large and complex in practice. hence, a corresponding challenge is how to deal with big data storage without having an adverse impact on the performance of blockchain network. • data sharing. in most existing healthcare systems, service providers usually maintain primary stewardship of data. with the notion of self-sovereignty, it is a trend to return the ownership of healthcare data back to the user who is capable of sharing (or not sharing) his personal data at will. it is also necessary to achieve secure data sharing across different organizations and domains. • data audit. audit logs can serve as proofs to hold requestors accountable for their interactions with ehrs when disputes arise. some systems utilize blockchain and smart contract to keep trace for auditability purpose. any operation or request will be recorded in the blockchain ledger, and can be retrieved at any time. • identity manager. the legitimacy of each user's identity needs to be guaranteed in 335 the system. in other words, only legitimate users can make the relevant requests to ensure system security and avoid malicious attacks. in the remaining of this section, we will review existing approaches to achieve data storage, data sharing, data audit, and identity manager (see sections 3.1 to 3.4). according to section 2.3, one of the solutions to ensure greater security in the ehr system is the use of blockchain technology. however, there are potential privacy problems for all of raw/encrypted data in the public ledger, since blockchain as a public database has the risk of sensitive data being exposed under the statistical attack. some measures should be taken to enhance the privacy protection of sensitive health record in the blockchain-based ehr systems. in generally, privacy preserving approaches can be classified into cryptographic and non-cryptographic approaches, including encryption, anonymisation and access control mechanism respectively. encryption scheme is a relatively common method, such as public key encryption 350 (pke), symmetric key encryption (ske), secure multi-party computation (mpc) [33] and so on. al. [35] proposed that sensors data will be uploaded using a pair of unique private and public keys in the blockchain network to protect the privacy and security of biometric information. zheng et al. [36] proposed that data will be encrypted before being uploaded to cloud servers by symmetric key scheme (i.e. rijndael aes [37] ) with threshold encryption 360 scheme. the symmetric key will be split into multiple shares distributed among different key keepers by shamir's secret sharing scheme [38] . only if data requestor gets enough key shares, he can decrypt the ciphertext. compromising of some key keepers(less than threshold) would not lead to data leakage. yue et al. [39] designed an app on smartphones based on blockchain with mpc tech-365 nique, called healthcare data gateway (hdg). the system allows to run computations of encrypted data directly on the private blockchain cloud and obtain the final results without revealing the raw data. besides, guo et al. [40] proposed an attribute-based signature scheme with multiple authorities (ma-abs) in the healthcare blockchain. the signature of this scheme attests 370 not to the identity of the patient who endorses a message, instead to a claim (like access policy) regarding the attributes delegated from some authorities he possesses. meanwhile, the system has the ability to resist collusion attack by sharing the secret pseudorandom function (prf) seeds among authorities. in order to resist malicious attacks (e.g. statistical attack), healthcare systems have 375 to change the encryption keys frequently of general methods. it will bring the cost for storage and management of a large amount of historical keys since these historical keys must be stored well to decrypt some historical data in future, then the storage cost will be greater, especially for limited computational resource and storage devices. to address this problem, zhao et al. [41] designed a lightweight backup and effi-380 cient recovery key management scheme for body senor networks (bsns) to protect the privacy of sensor data from human body and greatly reduce the storage cost of secret keys. fuzzy vault technology is applied for the generation, backup and recovery of keys without storing any encryption key, and the recovery of the key is executed by bsns. the adversary hardly decrypts sensor data without symmetric key since sensor data is 385 encrypted by symmetric encryption technology (i.e. aes or 3des). we compare and analyse some systems above, shown in table 1 and 2. most systems use cryptographic technology to enhance the security and privacy of healthcare data in the blockchain. however, encryption technique is not absolutely secure. the computational cost of encryption is high for some limited devices. transaction record may 390 also reveal user behaviors and identity because of the fixed account address. malicious attackers may break the ciphertext stored in the public ledger by some means. 2. all of data will be exposed once the corresponding symmetric key is lost table 2 : systems requirements that have been met in table 1 paper security privacy anonymity integrity authentication controllability auditability accountability [34] [35] [36] [39] [40] [42] [41] meanwhile, another important issue is key management. it is the foundation of entire data field safety that private keys do not reveal. the loss of private key means that the holder would have no ability to control the corresponding data. once the 395 private/symmetric key is compromised, all of data may be exposed by attackers. so, both encryption technique and key management should be considered when developers design a secure ehr system. additionally, it must guarantee that only authorized legitimate users can access private data to enhance security. non-cryptographic approaches mainly use access control 400 mechanism for security and preserving privacy. with regard to the security goals, access control mechanism is a kind of security technique that performs identification authenti-19 cation and authorization for entities. it is a tool widely used in the secure data sharing with minimal risk of data leakage. we will discuss this mechanism in details in the next section 3.2.2. the ehr systems can upload medical record and other information in the blockchain. if these data is stored directly in the blockchain network, it will increase computational overhead and storage burden due to the fixed and limited block size. what's more, these data would also suffer from privacy leakage. to solve these problems, most relevant research and applications [36, 42, 43, 44] yue et al. [39] proposed that a simple unified indicator centric schema (ics) could organize all kinds of personal healthcare data easily in one simple "table". in this system, data is uploaded once and retrieved many times. they designed multi-level index and most systems in the previous sections are adopted third-party database architecture. the third-party services (such as cloud computing) in the far-end assist the users to improve quality of service (qos) of the applications by providing data storage and computation power, but with a transmission latency. such a storage system has gained common acceptance depending on a trusted third table (dht). nguyen et al. [48] designed a system that integrates smart contract with ipfs to improve decentralized cloud storage and controlled data sharing for better user access management. rifi et al. [49] also adopted ipfs as the candidate for off-chain database to store large amounts of sensor personal data. 475 wang et al. [50] designed a system that utilizes ipfs to store the encrypted file. the encryption key of the file is first encrypted using abe algorithm, then encrypted with other information (file location hash ciphertext) using aes algorithm. only when the attributes set of the requestor meets the access policy predefined by data owner, the requestor can obtain the clue from blockchain, then download and decrypt the files from 480 ipfs. 22 table 4 : systems requirements that have been met in table 3 paper security privacy anonymity integrity authentication controllability auditability accountability [44] [47] [42] [45] [36] [43] [48] [49] [50] according to table 3 and 4, the common architecture for data storage in the ehr system is shown in fig. 5 . the advantages of integrating off-line storage into blockchain systems are as follows. first, detailed medical record is not allowed to access directly for patient's data privacy preserving. second, it helps to reduce the throughput require-485 ment significantly, since only transaction record and a few metadata are stored in the blockchain. besides, data pointers stored in the block can be linked to the location of raw data in the off-chain database for data integrity. however, it is difficult to fully trust the third parties to store these sensitive data. meanwhile, it may also contradict the idea of decentralization. further research is needed 490 to accelerate the acceptance of distributed storage systems in practice, like ipfs. also, the next step should be to improve the storage architecture of blockchain for high storage capacity. healthcare industry relies on multiple sources of information recorded in different sys-495 tems, such as hospitals, clinics, laboratories and so on. healthcare data should be stored, retrieved and manipulated by different healthcare providers for medical purposes. however, such a sharing approach of medical data is challenging due to heterogeneous data structures among different organizations. it is necessary to consider interoperability of 25 figure 5 : common architecture for data storage in the ehr system data among different organizations before sharing data. we will introduce interoperabil-500 ity first. interoperability of ehr is the degree to which ehr is understood and used by multiple different providers as they read each other's data. interoperability can be used to standardize and optimize the quality of health care. interoperability can mainly be 505 classified into three levels: • syntactic interoperability: one ehr system can communicate with another system through compatible formats. • semantic interoperability: data can be exchanged and accurately interpreted at the data field level between different systems. the lack of unified interoperability standards has been a major barrier in the highperformance data sharing between different entities. according to the study [51] , there in some studies [10, 52, 53] , they adopted the health level seven international (fhir) as data specification and standard formats for data exchange between different organi-520 zations. the criterion was created by hl7 healthcare standards organization. the system in [10] bahga et al. [56] proposed that cloud health information systems technology architecture (chistar) achieves semantic interoperability, defines a general purpose set of data structures and attributes and allows to aggregate healthcare data from disparate 545 data sources. besides, it can support security features and address the key requirements of hipaa. chen et al. [57] designed a secure interoperable cloud-based ehr service with continuity of care document (ccd). they provided self-protecting security for health documents with support for embedding and user-friendly control. in a word, interoperability is the basic ability for different information systems to communicate, exchange and use data in the healthcare context. ehr systems following international standards can achieve interoperability and support for data sharing between multiple healthcare providers and organizations. we will discuss data sharing in detail next. it is obviously inconvenient and inefficient to transfer paper medical record between different hospitals by patients themselves.sharing healthcare data is considered to be a critical approach to improve the quality of healthcare service and reduce medical costs. though current ehr systems bring much convenience, many obstacles still exist in 560 the healthcare information systems in practice, hinder secure and scalable data sharing across multiple organizations and thus limit the development of medical decision-making and research. as mentioned above, there are risks of the single-point attack and data leakage in a centralized system. besides, patients cannot preserve the ownership of their own private 565 data to share with someone who they trust. it may result in unauthorized use of private data by curious organizations. furthermore, different competing organizations lacking of trust partnerships are not willing to share data, which would also hinder the development of data sharing. in this case, it is necessary to ensure security and privacy-protection and return the 570 control right of data back to users in order to encourage data sharing. it is relatively simply to deal with security and privacy issues when data resides in a single organisa-tion, but it will be challenging in the case of secure health information exchange across different domains. meanwhile, it also needs to consider further how to encourage efficient collaboration in the medical industry. secure access control mechanism as one of common approaches requires that only authorized entities can access sharing data. this mechanism includes access policy commonly consisting of access control list (acl) associated with data owner. acl is a list of requestors who can access data, and related permissions (read, write, update) to specific data. authorization is a function of granting permission to authenticated users in order to access the protected resources following predefined access policies. the authentication process always comes before the authorization process. access policies of this mechanism mainly focus on who is performing which action on what data object for which purposes. traditional access control approaches for ehrs 585 sharing are deployed, managed and run by third parties. users always assume that third parties (e.g. cloud servers) perform authentication and access requests on data usage honestly. however, in fact, the server is honest but curious. it is promising that combining blockchain with access control mechanism is to build a trustworthy system. users can realize secure self-management of their own data and 590 keep shared data private. in this new model, patients can predefine access permissions (authorize, refuse, revoke), operation (read, write, update, delete) and duration to share their data by smart contracts on the blockchain without the loss of control right. smart contracts can be triggered on the blockchain once all of preconditions are met and can provide audit mechanism for any request recorded in the ledger as well. there 595 are many existing studies and applications applying smart contract for secure healthcare data sharing. peterson et al. [10] proposed that patients can authorize access to their record only under predefined conditions (research of a certain type, and for a given time range). smart contract placed directly on the blockchain verifies whether data requestors meet 600 these conditions to access the specified data. if the requestor does not have the access rights, the system will abort the session. similarly, smart contracts in [58] can be used for granting and revocation of access right and notifying the updated information as smart contract in most systems includes predefined access policies depending on requestors' role/purposes and based-role/based-purpose privileges. however, it is inflexible to handle unplanned or dynamic events and may lead to potential security threats [60]. another mechanism, attribute-based access control (abac), has been applied in the secure systems to handle remaining issues in the extensions of rbac and enhance the security in some specific cases. the systems based on access control mechanism record any operation about access policies by logging. however, it is vulnerable to malicious tampering without the assurance of integrity of these logs in the traditional systems. blockchain and smart contract can perform access authorization automatically in a secure container and make sure the integrity of policies and operations. thus, access control mechanism integrated with blockchain can provide secure data sharing. the diversified forms of access control can be applied into different situations depending on the demands for system security. audit-based access control aims to enhance the 670 reliability of posteriori verification [64] . organization-based access control (orbac) [65] can be expressed dynamically based on hierarchical structure, including organization, role, activity, view and context. 1. user's identity may be exposed without de-identification mechanism table 6 : systems requirements that have been met in table 5 paper security privacy anonymity integrity authentication controllability auditability accountability [10] [58] [44] [49] [48] [59] [39] [62] 36 table 6 : systems requirements that have been met in table 5 paper security privacy anonymity integrity authentication controllability auditability accountability [61] [66] [67] [68] [50] [69] [42] [70] [71] based on the information in the table 5 we can also use cryptography technology to enhance secure data sharing and the security of access control mechanism in most ehr systems. dubovitskaya et al. [66] proposed a framework to manage and share emrs for cancer patient care based on symmetric encryption. patients can generate symmetric encryption keys to encrypt/decrypt the sharing data with doctors. if the symmetric key is 685 compromised, proxy re-encryption algorithm on the data stored in the trusty cloud can be performed and then a new key will be shared with clinicians according to predefined access policies. only the patients can share symmetric keys and set up the access policies by smart contract to enhance the security of sharing data. xia et al. [67] designed a system that allows users to get access to requested data from 690 a shared sensitive data repository after both their identities and issuing keys are verified. in this system, user-issuer protocol is designed to create membership verification key and transaction key. user-verifier protocol is used for membership verification, then only valid users can send data request to the system. ramani et al. [68] utilized lightweight public key cryptographic operations to enhance 695 the security of permissioned requests (append, retrieve). nobody can change the patients' data without sending a notification to patients, since the requested transaction will be checked whether it has signed by the patient before being stored on a private blockchain. wang et al. [50] designed a system that combines ethereum with attribute-based encryption (abe) technology to achieve fine-grained access control over data in the de-700 centralized storage system without trusted private key generator (pkg). the encryption key of the file is stored on the blockchain in the encrypted format using aes algorithm. requestors whose attributes meet the access policies can decrypt the file encryption key and then download the encrypted file from ipfs. besides, the keyword search implemented by smart contract can avoid dishonest behavior of cloud servers. liu et al. [42] proposed blockchain-based privacy-preserving data sharing scheme for emr called bpds. the system adopted content extraction signature (ces) [73] 715 which can remove sensitive information of emrs, support for selective sharing data and generate valid extraction signatures to reduce the risk of data privacy leakage and help enhance the security of access control policies. besides, users can use different public keys for different transactions to keep anonymous. huang et al. [70] designed a blockchain-based data sharing scheme in the cloud com-720 puting environment to solve the trust issue among different groups using group signature and ensure the reliability of the data from other organizations. requestors can verify the as shown in table 5 and 6, cryptography technology can protect sensitive data directly and improve the traditional access control mechanism to meet the demand for security and privacy. however, public key encryption has high computational overhead 735 and trusted pki is necessary for authentication. the similar problem exists in a trusted pkg as one of important components of abe. besides, how to transmit the shared key securely should be addressed in the symmetric encryption. as mentioned before, mpc may not be suitable for wearable devices in the iot context due to high computational cost. it is necessary to improve these algorithms to adapt devices/sensors with limited 740 resource. above all, blockchain as a secure, immutable and decentralized framework makes the 39 control right of data return to patients themselves in the healthcare industry. as shown in fig. 6 , the combination of access control mechanism by smart contract with cryptography technology on sensitive data can be achieved secure data sharing among different 745 individuals and institutions. meanwhile, all of record is included in the immutable public ledger to ensure the integrity and reliability of data and minimize the risk of raw data leakage. concerning potential dishonest behavior or wrong results of third parties (cloud servers) holding large amounts of raw/encrypted data, blockchain offers immutable his-750 torical record for traceability and accountability, sometimes with cryptography technique (such as group signature). next we discuss about secure audit to enhance the security of ehr systems further. healthcare systems also rely on audit log management as security mechanism since 755 some exceptions may have resulted from the misuse of access privileges or dishonest behavior by third parties or data requestors. audit log can serve as proofs when disputes arise to hold users accountable for their interactions with patient record. immutable public ledger and smart contract in the blockchain can provide immutable record for all of access requests to achieve traceability and accountability. audit log mainly contains vital and understandable information: • timestamp of logged event • user id which requests the data • data owner id whose data is accessed • action type (create, delete, query, update) • the validation result of the request qi et al. [74] designed a data sharing model with the ability to effectively track the dishonest behaviour of sharing data as well as revoke access right to violated permissions and malicious access. the system provides provenance, audit and medical data sharing among cloud service providers with minimal risk of data privacy. the similar system in [67] provides auditable and accountable access control for shared cloud repositories among big data entities in a trust-less environment. azaria et al. [53] also provided auditability via comprehensive log. they mentioned that obfuscation for privacy needs further exploration while preserving auditability in the public ledger. fernandez et al. [75] designed a blockchain-based system called auditchain to manto improve quality of research by better reproducibility, the timestamped statistical analysis on clinical trials ensures traceability and integrity of each samples metadata in [77] based on blockchain which allows to store proofs of existence of data. the related analytical code to process the data must be timestamped in order that data is checked 790 and analysis is reproducible. timestamp in the blockchain will provide for better version control than git. the above-mentioned studies indicate that blockchain plays an important role in auditing and accountability. users can not only hold the control right of their own data, but also monitor all request operations for data audit and accountability when disputes 795 occur. above all, audit log provides reliable evidence for anomalous and potentially malicious behavior to improve the security of access control models. meanwhile, it brings benefits to the adjustment of healthcare service by gaining insight into personnel interactions and workflows in hospitals. store and process. currently, audit log data does not contain required and representative information reliably, which would be difficult to interpret or hardly access. it would get worse in the collaboration of multiple ehr organizations. in this case, it is necessary to consider how to achieve interoperable and well-formatted audit log standard for the 805 support of secure data exchange among different healthcare institutions. membership verification is the first step to ensure the security of any system before getting access to any resource. in the access control mechanism mentioned before, identity authentication is always first performed to make sure that specific rights are granted 810 to data requestors with legal identity before sharing data. common types of user authentication have pass-through authentication, biometric authentication and identity verification based on public key cryptography algorithms. public key infrastructure (pki) is commonly used, which relies on trusted third parties to provide membership management services. identity registration is performed in [44] with registrar smart contract to map valid string form of identity information to a unique ethereum address via public key cryptography. it can employe a dns-like implementation to allow the mapping of regulate existing forms of id. 835 zhang et al. [69] established secure links for wireless body area network (wban) area and wireless body area network (psn) area after authentication and key establishment through an improved ieee 802.15.6 display authenticated association protocol [78] . the protocol can protect collected data through human body channels (hbcs) and reduce computational load on the sensors. 840 xia et al. [67] designed an efficient and secure identity-based authentication and key agreement protocol for membership authentication with anonymity in a permissioned blockchain. the process of verification is a challenge-response dialog to prove whether the sender is authentic when the verifier receives a verification request from a user using shared key. most blockchain-based systems use pseudonyms to hide the real identity for privacy. however, there is conflict between privacy preserving and authenticity. that means how to verify the identity without exposing the information of real identity. in addition, adversaries or curious third parties can guess the real identity and relevant behavior pattern through inference attacks, such as transaction graph analysis. 850 shae et al. [79] designed an anonymous identity authentication mechanism based on zero-knowledge technology [80] , which can address two conflicting requirements: maintain the identity anonymous and verify the legitimacy of user identity as well as iot devices. sun et al. [45] proposed a decentralizing attribute-based signature (called dabs) scheme to provide effective verification of signer's attributes without his identity infor-855 mation leakage. multiple authorities can issue valid signature keys according to user's attributes rather than real identity and provide privacy-preserving verification service. other nodes can verify whether the data owner is qualified by verification key corresponding to satisfied attributes without revealing owner identity. hardjono et al. [81] designed an anonymous but verifiable identity scheme, called 860 chainachor, using the epid zero-knowledge proof scheme. these anonymous identities can achieve unlinkable transactions using different public key in the blockchain when 43 nodes execute zero-knowledge proof protocol successfully. they also provide optional disclosure of the real identity when disputes occur. biometric authentication is also widely used, such as face and voice pattern identifi-865 cation, retinal pattern analysis, hand characteristics and automated fingerprint analysis based on pattern recognition. lee et al. [35] proposed that human nails can be used for identity authentication since nails have the high degree of uniqueness. the system uses histogram of oriented gradients (hog) and local binary pattern (lbp) feature to extract the biometric identification 870 signature, then svm and convolutional neural network are utilized for authentication with high accuracy. this identity verification technology with dynamic identity rather than regular real identity information ensures user anonymity and privacy. the main goal of identity management is to ensure that only authenticated users can be authorized to access the specified resource. currently, most systems rely on 875 membership service component or similar providers for identity authentication. traditional authentication process mainly adopts password authentication and even transmit user account in the clear text. anyone can eavesdrop on the external connection to intercept user account. in this case, attackers or curious third parties may impersonate compromised users to gain access to sensitive data. it is difficult to find and rely on such a trustworthy third membership service party that validates user identity and accomplishes complex cross-heterogeneous domains authentication honestly without potential risk of real identity leakage. besides, typical blockchain systems cannot provide privacy-preserving verification due to public transaction record including pseudonyms and related behavior. in this case, curious third 885 servers or network nodes may collect large amounts of data to infer the real identity by statistical analysis. blockchain can also allow rollback models storage if false predication rate is high. blockchain stores the pointers of relevant data of retrained models in a secure and immutable manner. juneja et al. [43] proposed that retraining models indexed by pointers 930 in the blockchain can increase the accuracies for continuous remote systems in the context of irregular arrhythmia alarm rate. additionally, artificial intelligence can be applied to design automatic generation of smart contact to enhance secure and flexible operations. in the context of iot, the locations of products can be tracked at each step with radio-frequency identification (rfid), sensors or gps tags. individual healthy situation can be monitored at home via sensor devices and shared on the cloud environment where physical providers can access to provide on-time medical supports. however, as the use of sensors is experiencing exponential growth in various environ-940 ments, the security level of sensitive data of these sensors has to be improved. currently, a few studies focus on solving the above mentioned problems. related 980 research mainly focuses on the improvement of consensus algorithm, block size design [67] and so on. croman et al. [89] mainly improved the scalability of blockchain on latency, throughput and other parameters. the experiments showed that block size and generation inter-val in bitcoin are the first step toward throughput improvements and latency reduction without threat to system decentralization. new challenges for two data types in the blockchain-based system are throughput and fairness. two fairness-based packing algorithms are designed to improve the throughput 1000 and fairness of system among users. in the practical application scenario, how to encourage miners to participate in the network is important for the maintenance of trustworthy and stable blockchain. azaria et al. [44] proposed an incentive mechanism to encourage medical researchers and healthcare authorities as miners and create data economics by awarding for big data on hospital 1005 records to researchers. yang et al. [92] proposed a selection method in the incentive mechanism. providers have less significance (means the efforts that providers have been made on network maintenance and new blocks generation) with higher probabilities of being selected to carry out the task of new block generation and will be granted significance as bonus to reduce 1010 the selected probability in future. pham et al. [93] made further improvements on gas prices of blockchain, which can boost the priority in the processing transaction queue by automatically adjusting the gas price and then trigger an emergency contact to providers for on-time treatment immediately. meanwhile, it should be noted that all transactions can be "seen" by any node in the blockchain network. homomorphic encryption and zero knowledge proofs could be utilized to prevent data forensics by inference, maintain the privacy of individual information and allow computations to be performed without the leakage of input and output of computations. as the above statement, blockchain still has many limitations and more aggressive extensions will require fundamental protocol redesign. so it is urgent to be towards to the improvement of underlying architecture of blockchain for better service. in the context of iot, personal healthcare data streams collected from wearable devices are high in volume and at fast rate. large amounts of data can support for big 1025 data and machine learning to increase the quality of data and provide more intelligent health service. however, it may lead to high network latency due to the physical distance to mobile devices and traffic congestion on the cloud servers. besides, the mining process and some encryption algorithms may cost high computational power on resource-limited devices 1030 and restrict the use of blockchain. a new trend is increasingly moving from the function of clouds towards network edge with low network latency. it is mainly required by time-sensitive applications, like healthcare monitor applications. combining with edge computing, blockchain is broadened to a wide range of services from pure data storage, such as device configuration 1035 and governance, sensor data storage and management, and multi-access payments. if new technologies enter the market without some form of vetting, they should be adopted with care for example based on a cost-benefit-analysis. hence, to improve compliance, security, interoperability and other factors, we need to develop uniform stan-1040 dards, policies and regulations (e.g. those relating to data security and privacy, and blockchain ecosystem). for example, we would likely need different independent and trusted mechanisms to evaluate different blockchain solutions for different applications and context, in terms of privacy, security, throughput, latency, capacity, etc. we would also need to be able to police and enforce penalty for misbehavior and/or violations (e.g. non-compliance or not delivering as agreed in the contract). blockchain has shown great potential in transforming the conventional healthcare industry, as demonstrated in this paper. there, however, remain a number of research and operational challenges, when attempting to fully integrate blockchain technology 1050 with existing ehr systems. in this paper, we reviewed and discussed some of these challenges. then, we identified a number of potential research opportunities, for example relating to iot, big data, machine learning and edge computing. we hope this review will contribute to further insight into the development and implementation of the next generation ehr systems, which will benefit our (ageing) society. healthcare professionals organisational barriers to health information technologiesa lit-1065 erature review maturity models of healthcare information systems and technologies: a literature review security and privacy in electronic health records: a systematic literature review implementing electronic health records in hospitals: a systematic literature review electronic health record use by nurses in mental health settings: a literature review personal electronic healthcare records: what influences consumers to engage with their clinical data online? a literature review methodologies for designing healthcare analytics solutions: a literature analysis opportunities and challenges in healthcare information systems research: caring for patients with chronic conditions visualization of blockchain data: a systematic review a blockchain-based approach to health information exchange networks blockchain in healthcare applications: research challenges and opportunities blockchain: a panacea for healthcare cloud-based data security and privacy? 2017 ieee technology & engineering management conference (temscon) blockchain technology in healthcare: the revolution starts here bitcoin: a peer-to-peer electronic cash system dcap: a secure and efficient decentralized 1100 conditional anonymous payment system based on blockchain an efficient nizk scheme for privacy-preserving transactions over account-model blockchain a survey on privacy protection in blockchain system secure and efficient two-party signing protocol for the identity-based signature scheme in the ieee p1363 standard for public key cryptography multi-party signing protocol for the identitybased signature scheme in ieee p1363 standard the byzantine generals problem a survey on consensus mechanisms and mining strategy management in blockchain networks practical byzantine fault tolerance ethereum: blockchain app platforms multichain: open platform for building blockchains forensic-by-design framework for cyberphysical cloud systems medical cyber-physical systems development: a forensics-driven approach sdte: a secure blockchain-based data trading ecosystem class: cloud log assuring soundness and secrecy scheme for cloud forensics enigma: decentralized computation platform with guaranteed privacy medibchain: a blockchain based privacy preserving platform for healthcare data fingernail analysis management system using microscopy sensor and blockchain technology ordieres-mere, blockchain-based personal health data sharing system using cloud storage the design of rijndael: aes -the advanced encryption standard. 1150 [38] s. vanstone, a. menezes, p. v. oorschot, handbook of applied cryptography healthcare data gateways: found healthcare intelligence on blockchain with novel privacy risk control secure attribute-based signature scheme with multiple authorities for blockchain in electronic health records systems lightweight backup and efficient recovery scheme for health blockchain keys bpds: a blockchain based privacy-preserving data sharing for electronic medical records leveraging blockchain for retraining deep learning architecture in patientspecific arrhythmia classification medrec: using blockchain for medical data access 1165 and permission management a decentralizing attribute-based signature for healthcare blockchain using java to generate globally unique identifiers for dicom objects a framework for secure and decentralized sharing of medical imaging data via blockchain consensus blockchain for secure ehrs sharing of 1175 mobile cloud based e-health systems towards using blockchain technology for ehealth data access management a blockchain-based framework for data sharing with fine-grained 1180 access control in decentralized storage systems an overview of interoperability standards for electronic health records, usa: society for design and process science 2018 ieee international conference on bioinformatics and biomedicine medrec: using blockchain for medical data access and permission management fhirchain: applying blockchain 1190 to securely and scalably share clinical data applying software patterns to address interoperability in blockchain-based healthcare apps a cloud-based approach for interoperable electronic health records 1195 (ehrs) design for a secure interoperable cloud-based personal health record service how distributed ledgers can improve provider data management and support 1200 interoperabilityhttps integrating blockchain for data sharing and collaboration in mobile healthcare applications security and privacy in electronic health records: a systematic literature review blockchain for access control in e-health scenarios blockchain based access control servicesdoi blockchain based delegatable access control scheme for a collaborative e-health environment audit-based access control with a distributed ledger: applications to healthcare organizations organization based access control secure and trustable electronic medical records sharing using blockchain bbds: blockchain-based data sharing for electronic medical records in cloud environments secure and efficient data accessibility in blockchain based healthcare systems a secure system for pervasive social network-based healthcare blockchain-based multiple groups data sharing with anonymity and traceability privacy-preserving attribute-based access control model for xml-based electronic health record system dynamic access control policy based on blockchain and machine learning for the internet of things content extraction signatures medshare: trust-less medical data sharing among cloud service providers via blockchain security and privacy in electronic health records: a systematic literature review improving data transparency in clinical trials using blockchain smart contracts blockchain technology for improving clinical research quality blockchain distributed ledger technologies for biomedical 1250 and health care applications on the design of a blockchain platform for clinical trial and precision medicine non-interactive zero-knowledge and its applications verifiable anonymous identities and access control in permissioned blockchains big data: are biomedical and health informatics training programs ready? privacy preserving in blockchain based on partial homomorphic encryption system for ai applications a fully homomorphic encryption scheme an architecture and protocol for smart continuous ehealth monitoring using 5g 5g-smart diabetes: toward personalized diabetes 1270 diagnosis with healthcare big data clouds permissioned blockchain and edge computing empowered privacy-preserving smart grid networks integrated blockchain and edge computing systems: a survey, some research issues and challenges blochie: a blockchain-based platform for healthcare information exchange a design of blockchain-based architecture for the security of electronic health record (ehr) systems a secure remote healthcare system for hospital using blockchain smart contract shuyun shi received the bachelor degree in 2019, from the school of computer 1290 she is currently working toward a master degree at the key laboratory of aerospace information security and trusted computing ministry of education he is currently a professor of the key laboratory of aerospace information security and trusted computing, ministry of education, school of cyber science and engineering, wuhan uni-1300 versity, wuhan 430072, china. his main research interests include cryptography and information security li li received her ph.d degree in computer science from computer school she is currently an associate professor at school of software, wuhan univer-1305 sity. her research interests include data security and privacy, applied cryptography and security protocols his research is focused on mobile computing, parallel/distributed computing, multi-agent systems, service oriented computing, routing and security issues in mobile ad hoc, sensor and mesh networks. he has more than 100 technical research papers in leading journals such as-ieee tii his research is supported from dst, tcs and ugc. he has guided many students leading to m.e. and ph.d australia day achievement medallion, and british computer society's wilkes award in 2008. he is also a fellow of the australian computer society digital rights management for multimedia interest group we thank the anonymous reviewers for their valuable comments and suggestions which helped us to improve the content and presentation of this paper. the authors declare that they have no conflicts of interest. 61 key: cord-327300-dvlb61tw authors: abu, thelma zulfawu; elliott, susan j. title: when it is not measured, how then will it be planned for? wash a critical indicator for universal health coverage in kenya date: 2020-08-08 journal: int j environ res public health doi: 10.3390/ijerph17165746 sha: doc_id: 327300 cord_uid: dvlb61tw the quality and safety of healthcare facility (hcf) services are critical to achieving universal health coverage (uhc) and yet the who/unicef joint monitoring program for water supply, sanitation and hygiene report indicates that only 51% and 23% of hcf in sub-saharan africa have basic access to water and sanitation, respectively. global commitments on improving access to water, sanitation, hygiene, waste management and environmental cleaning (wash) in hcf as part of implementing uhc have surged since 2015. guided by political ecology of health theory, we explored the country level commitment to ensuring access to wash in hcfs as part of piloting uhc in kisumu, kenya. through content analysis, 17 relevant policy documents were systematically reviewed using nvivo. none of the national documents mentioned all the component of wash in healthcare facilities. furthermore, these wash components are not measured as part of the universal health coverage pilot. comprehensively incorporating wash measurement and monitoring in hcfs in the context of uhc policies creates a foundation for achieving sdg 6. accessing quality health services is a challenge, especially in the global south. lack of access to water, sanitation, hygiene, waste management and environment cleaning (wash) undermine the quality of services provided in healthcare facilities [1, 2] . the absence or inadequacy of safe wash in healthcare facilities compromises infection prevention and control, patient safety and child and maternal health [3] . meanwhile, the who/unicef joint monitoring program for water supply, sanitation and hygiene reported that in sub-saharan africa (ssa), only 51 percent of healthcare facilities have access to basic water services and 23 percent have access to basic sanitation services. forty-one percent of healthcare facilities have basic waste management services. data on hygiene and environmental cleaning in healthcare facilities were inconclusive due to inadequate monitoring [1] . similarly, cronk and bartram [2] evaluated the environmental conditions of healthcare facilities in 78 low-and middle-income countries (lmics) and found that only two percent of the healthcare facilities provided water, sanitation, hygiene and waste management services. also, ensuring access to wash in healthcare facilities extends beyond disease control to issues of dignity and respect. for example, women after childbirth in healthcare facilities require a clean bathroom with running water to maintain their personal hygiene. kohler, renggli, & lüthi [4] in a comparative study in india and uganda sought to address the gender gap in access to wash in healthcare facilities. they undertook a needs assessment in hygiene and sanitation issues during menstruation and childbirth among women in selected maternal ward and inpatient facilities which were run by government. wash in healthcare facilities were assessed based on hygiene and health, security and safety, privacy, accessibility, comfort and menstrual hygiene management. from their study, lack of safe wash infrastructure and menstrual hygiene facilities were a burden for women in both countries. in addition, gon et al. in 2016 engaged in a study to investigate the status of water and sanitation in relation to childbirth in healthcare facilities and homes. from their study, less than 50 percent of all delivery facilities and homes had access to wash in all countries [5] . for example, in kenya, 18 percent of women delivered with improved access to water and sanitation. furthermore, climate change and variability and conflicts burden the functioning of wash in healthcare facilities. first, 90 percent of disasters in ssa, especially the horn of africa, are water-related [6] . prolonged drought and floods have affected the quantity and quality of water available [7, 8] . second, displaced people face wash related challenges and these events increase health risks and disease outbreaks such as cholera [9, 10] . prior global commitments on ensuring access to wash were concentrated at the household level to the neglect of institutions. the widespread effects of ebola in 2014 even in healthcare facilities leading to the loss of several healthcare workers [11] [12] [13] and the subsequent world health organization assessment on wash in healthcare facilities in 2015 initiated discussions and led to several global commitments to address this challenge of infection prevention and control in healthcare facilities. at the global stage currently, significant efforts towards ensuring access to wash have included and prioritized public spaces such as healthcare facilities. this is included in the sustainable development goals (sdg). goal 6 seeks to ensure access to water and sanitation. targets 6.1 and 6.2 of the sdgs highlight the need to expand wash monitoring by relevant stakeholders in non-household settings, such as healthcare facilities. similarly, goal 3 seeks to ensure healthy lives and promote wellbeing for all at all ages. target 3.8 highlights achieving universal health coverage which does not just incorporate reducing the financial burden of people, but further ensuring quality essential healthcare services for all. similarly, in 2015, world leaders adopted the sendai framework for disaster risk reduction (drr) and one of its targets is to substantially reduce disaster damage to critical infrastructure and disruption of basic services, among them health facilities through developing their resilience by 2030 [14] . this framework was a paradigm shift from managing disasters to disaster risk reduction. achieving this target means ensuring the effectiveness and efficiency of all the components of a health system, including wash. in march 2018, as part of the launch of international decade for action "water for sustainable development 2018-2028", the un secretary general also made a global call to action for wash in all healthcare facilities [15] . in response, various ministers of state signed the world health assembly resolution on wash in healthcare facilities as part of the implementation of universal health coverage scheme. in addition, various assessment tools, healthcare facility guidelines and frameworks on wash were published by the global community especially world health organization. however, it is evident from research that socially and institutionally driven challenges such as lack of data and knowledge are major hindrances to improved service provision such as healthcare in ssa [10, 16, 17] . for instance, adjei, sambu & smiley [18] explored historical and emerging policies and institutional arrangements surrounding urban water supply in sub-saharan africa. the persistent lack of water in urban areas was attributed to weak institutional arrangements and poor enforcement of legislations. the authors recommended the need for institutional rectification to achieve the sustainable development goals by 2030. similarly, maina et al. [3] in their study on the role of wash on antimicrobial resistance in healthcare facilities in kenya highlighted the need for government institutional support for healthcare managers to enable them achieve access to basic wash in healthcare facilities. it is evident from research that the availability and enforcement of regulations such as policies and legislations on an agenda enhance their achievement [19] . guo & bartram [20] in their investigation on the predictors for water quality in rural healthcare facilities concluded that the presence of a protocol for operation and management in a facility was associated with safe water use. following this, there is little research to understand the implementation process or the institutional arrangements of wash in healthcare facilities and the influence of global commitments on country level policy environment on ensuring access to wash in health facilities in ssa. therefore, this paper reviews the framing of wash in healthcare facilities in relevant global and country-level institutional documents (policies, legislations, guides, plans and monitoring tools) using kenya as a case study. following the introduction, the second section explores the theoretical framing of this paper, the political ecology of health theory. the third section explores the study context, kenya. the fourth section indicates the methods of data collection and analyses. the presentation of the results and discussion make up the fifth and sixth sections, respectively. the seventh section concludes the paper with a summary of the key points and emphasizing the relevance of wash in healthcare facilities to sdg 3 and sdg 6. social theories provide a more comprehensive connection between determinants and processes of health and wellbeing [21] [22] [23] . the paper is guided by political ecology of health theory, which explores how power, politics, structures, agendas and/or agents shape the environment and health risks of populations [24, 25] . this theory further explores how growing discourse on health at the global scale influence and shape local contexts such as policies development and implementation. the prioritization, implementation and management of wash interventions are political and power-laden at the global, national and local levels [26] . this theory has been useful in the study of prioritization and implementation of development projects and health and wellbeing of local populations [27] [28] [29] . it has also guided studies in healthcare services in lmics [24] and privatization of water and its impacts on health and wellbeing [30] . kenya is an east african country with an estimated population of about 48 million [31] . the country has 47 counties. according to the kenyan health policy 2012-2030, kenya has an agenda to implement universal health coverage and achieve countrywide coverage by 2022. in 2018, the universal health coverage scheme was launched and currently piloted in four counties, kisumu, isiolo, machakos and nyeri. a policy brief written by wangia & kandie [32] and published by the ministry of health with a focus on quality of care and essential elements in attaining universal health coverage in kenya indicated the need for appropriate water and sanitation infrastructure in healthcare facilities. according to the who/unicef joint monitoring program for water supply, sanitation and hygiene report based on 2016 data, only 65% of healthcare facilities in kenya had access to basic water services. this served a population of 31, 784, 828 people. healthcare facilities with limited and no water services were 17.6 percent and 16.8 percent, respectively. concerning sanitation in healthcare facilities, monitoring and data collection was inadequate. eighty-six percent of healthcare facilities had insufficient data and 14 percent of healthcare facilities recorded no sanitation services. regarding hygiene, insufficient data for 99.6 percent of healthcare facilities was recorded. in addition, 0.4 percent of the healthcare facilities recorded no hygiene services. only 33.1 percent of healthcare facilities recorded basic waste management services, 62.1 percent recorded limited services and 4.8 percent reported no waste management services. for environmental cleaning in healthcare facilities data were insufficient for comprehensive and conclusive analysis. from these data it is evident that access, regular monitoring and evaluation of wash in healthcare facilities are major challenges. other researchers such as bennett, otieno, ayers, & odhiambo [33] , essendi et al. [34] and maina et al. [3] have reported lack of wash in healthcare facilities in kenya in their studies. in addition, at the community level, residents questioned the quality of healthcare delivery in hospitals without the appropriate wash infrastructure [35, 36] . according to wangia & kandie [32] , quality care is not yet a legal requirement and issues such as poor enforcement of legislation and minimal information on quality of care especially in private facilities will negatively impact achieving universal health coverage. other key challenge to accessing wash in healthcare facilities are climate variability and civil disruptions. the amount of rainfall affects the quantity and quality of water available for use in most marginalized communities. the struggle to access safe water is worsened in the face of climate variability. floods from torrential rains and effects of drought from prolonged dry seasons have displaced many citizens, especially in rural and marginalized areas. as of september 2017, about 5.6 million kenyan citizens were in need due to several episodes of drought [9] . kenya has also recorded an increasing influx of migrants from neighboring countries greatly affected by drought. these people are further exposed to health hazards subsequently increase attendance at healthcare facilities. kenya has a partial plan to support ensuring access to wash in health care facilities [10] . despite progress and new initiatives, more needs to be done to understand and solve the challenge of lack of wash in healthcare facilities. qualitative content analysis was used to analyze the framing of wash in healthcare facilities in relevant documents for this paper. relevant wash in healthcare facility documents such as policies, legislations, guidelines, plans and monitoring tools were gathered for this research from may 2019 to june 2020. documents included in this research were accessed using two methods. first, desktop searches were conducted to identify and access current and operational wash in healthcare facility documents. desktop searches on key phrases like "wash in healthcare facilities", "quality care" and "universal health coverage" were done using google and google scholar. the websites of the ministry of health, kenya, world health organization, who/unicef joint monitoring program for water supply, sanitation and hygiene as well as the official website for wash in healthcare facilities were searched for relevant documents. second, the ministry of health, kisumu county office, kenya was contacted in person by researchers from june 2019-september 2019 for relevant documents on wash in healthcare facilities. current operational documents guiding the implementation and monitoring of wash in healthcare facilities, quality healthcare and the piloted universal health coverage as of september 2019 were sought at the ministry. documents included in this study were based on three criteria after been carefully screened. first documents comprehensively indicated wash in healthcare facilities or/and health care (quality care and universal health coverage) as their focus. second, current and operational national documents with an agenda on wash in healthcare facilities, quality care in healthcare facilities and universal health coverage were also considered. third, document was listed by relevant key stakeholders identified and interviewed at the ministry of health, kisumu county office. the documents included in this study were published from 2007 to 2019. documents prior to 2015 when the upsurge in campaigns for wash in hcfs and uhc were included because they set the foundation for drafting current wash in hcf guidelines and policies. table 1 shows a list of relevant documents included in this research. first, the documents were categorized based on scale-global and national. second, based on the purpose of the document-legislation, policy, guidelines, monitoring tool and plans. in total, 17 documents were included, five (5) global level documents and eight (12) national level documents regulating issues of wash in healthcare facilities. two of the twelve national documents are county level documents. kenya has a decentralized government system and the counties have the power to contextualize national policies or develop policies that meet their needs. a coding frame (table 2 ) was developed to guide the coding process. the frame was guided by the logic framework (input, activities, output and impact), heuristic framework (agenda setting, formulation, implementation and evaluation) [37] and policy triangle (grounded in a political economy perspective and considers actors, context, process and content shape policymaking) [38] . the authors adapted the washfit conceptual framework [39, 40] . it is a framework designed to help implementers identify risks in healthcare facilities and it provides practical tools and templates for managing wash and facilities. themes developed for coding were first guided by the water-health nexus. cook & bakker [41] define water security as "sustainable access on a watershed basis to adequate quantities of water, of acceptable quality, to ensure human and ecosystem health". this definition embodies two sdgs, sdg 3-good health and wellbeing, of particular interest to this research is target 3.8 (achieve universal health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all) and sdg 6, clean water and sanitation for all. in addition, the key components of wash-water, sanitation, hygiene, waste management and environmental cleaning were adapted from the who/unicef joint monitoring program for water supply, sanitation and hygiene. key indicators for monitoring wash in healthcare facilities and categorized as improved, basic, limited and no service [1] . guided by this coding frame, a coding schedule (tables 3-5) was developed for coding. content analysis was done deductively using nvivo 12. key phrases like wash in healthcare facilities, universal health coverage, wash in healthcare facility stakeholders and quality care were coded. this research explored the framing of wash in healthcare facilities in relevant global and national policies, guidelines, monitoring tools and legislations. from the content analysis, five (5) global documents comprehensively mentioned wash in healthcare facilities. two national level documents mentioned water, sanitation and hygiene in phrases or sentences while environmental cleaning and waste management were excluded. "the core indicators define "basic" service levels for water, sanitation, hygiene, health care waste management and environmental cleaning in health care facilities" (core questions and indicators for monitoring wash in health care facilities in the sustainable development goals) the need to ensuring access to water, sanitation and hygiene in health care facilities was mentioned: "ensure that all new health facilities are appropriately designed and constructed with reliable water supply and environmental sanitation and hygiene facilities, including toilet and hand-washing facilities, taking into account gender, age and disability considerations" (kenya environmental sanitation and hygiene policy 2016-2030). "facility design and planning should ensure the following: adequate supply of safe water, adequate floor space for beds, adequate space between beds, adequate hand-washing facilities, adequate sanitary facilities" (national infection prevention and control guidelines for health care services in kenya, 2010). the global documents serve as a guide for national wash in healthcare facility implementation. they also specify the core areas of wash in healthcare facilities that need facility managers and implementers attention: "to develop and implement a road map according to national context so that every healthcare facility in every setting has, commensurate with its needs: safely managed and reliable water supplies; sufficient, safely managed and accessible toilets or latrines for patients, caregivers and staff of all sexes, ages and abilities; appropriate core components of infection prevention and control programmes, including good hand hygiene infrastructure and practices; routine, effective cleaning; safe waste management systems, including those for excreta and medical waste disposal; and, whenever possible, sustainable and clean energy" (a72_r7 wash in healthcare facilities resolutions). the global wash in healthcare facilities documents also set a monitoring standard for countries given in-country monitoring indicators on wash in healthcare facilities are often not comprehensive: "in support of sdg monitoring and to allow for comparable data to be generated within and between countries, a core set of harmonized indicators and questions that address basic wash services in health care facilities that will be applicable in all contexts is needed" (core questions for monitoring wash in healthcare facilities in the sustainable development goals). the individual components of wash were highlighted in the documents assessed. the various components are outlined below. recommended water sources for healthcare facilities include piped water, boreholes or tube wells, protected dug wells, protected springs, rainwater and packaged or delivered water. the theme water in healthcare facilities was mentioned in nine (9) documents of which four were national documents. some documents highlighted the need for water in healthcare facilities: "sufficient water-collection points and water-use facilities are available in the health center to allow convenient access to, and use of, water for drinking, food preparation, personal hygiene, medical activities, laundry and cleaning" (essential environmental health standards in healthcare). the types of water systems in healthcare facilities were also mentioned in some documents: "improved water sources in healthcare settings include piped water, boreholes/tube wells, protected wells, protected springs, rainwater and packaged or delivered water" (washfit, a practical guide for improving quality of care through wash in hcfs). at the national level, the water act mentions the provision of water in healthcare facilities: "nothing in this section prohibits-(a) the provision of water services by a person to his employees; or (b) the provision of water services on the premises of any hospital, factory, school, hotel, brewery, research station or institution to the occupants thereof, in cases where the source of supply of the water is lawfully under its control or where the water is supplied to it in bulk by a licensee" (water act cap 372). recommended sanitation infrastructure includes flush/pour flush to piped sewer system, septic tanks or pit latrines; ventilated improved pit latrines, composting toilets or pit latrines with slabs. sanitation in healthcare facilities was highlighted in five (5) global documents and three (3) national documents. basic sanitation service was defined as follows: "basic sanitation services definition: proportion of health care facilities with improved and usable sanitation facilities, with at least one toilet dedicated for staff, at least one sex-separated toilet with menstrual hygiene facilities, and at least one toilet accessible for users with limited mobility" (core questions in monitoring wash in healthcare facilities in the sustainable development goals). the maintenance of sanitary infrastructure was highlighted. "ensuring houses, institutions, hospitals and other public places maintain environment to the highest level of sanitation attainable to prevent, reduce or eliminate environmental health risks" (kenya health act no.21 of 2017). hygiene infrastructure include sink with tap, water tank with tap, bucket with tap or similar device, alcohol based hand rub dispensers. hygiene in healthcare facilities was highlighted in eight documents analyzed. three (3) national level documents and five (5) global documents. hygiene was defined as: "basic hygiene services definition: proportion of health care facilities with functional hand hygiene facilities available at one or more points of care and within 5 meters of toilets" (core questions for monitoring wash in healthcare facilities in the sustainable development goals). the importance of hygiene facilities was also highlighted in some documents, for example: "hand hygiene is the single most important ipc precaution and one of the most effective means to prevent transmission of pathogens associated with health care services. appropriate hand hygiene must be carried out upon arriving at and before leaving the health care facility, as well as in the following circumstances" (national infection prevention and control guidelines for health care services in kenya) waste management in healthcare facilities was highlighted in nine (9) documents. different types of waste are generated from various sectors of the healthcare facility as a result waste segregation was highly illustrated in the documents: "the four major categories of health-care waste recommended for organizing segregation and separate storage, collection and disposal are: • sharps (needles, scalpels, etc.), which may be infectious or not • non-sharps infectious waste (anatomical waste, pathological waste, dressings, used syringes, used single-use gloves) • non-sharps non-infectious waste (paper, packaging, etc.) • hazardous waste (expired drugs, laboratory reagents, radioactive waste, insecticides, etc.)" (essential environmental health standards in healthcare). it is recommended colors and images be used to identify waste containers and waste should be appropriately disposed by incineration, autoclaving and burial in a lined, protected pit. the repercussions of improper healthcare waste management were mention. "review medical waste management guidelines for health care facilities to protect public health and safety, provide a safer working environment, minimize waste generation and environmental impacts of medical waste disposal and ensure compliance with legislative and regulatory requirements" (kenya environmental sanitation and hygiene policy 2016-2030). basic environmental cleaning in a healthcare facility was defined as: "definition: proportion of health care facilities which have protocols for cleaning, and staff with cleaning responsibilities have all received training on cleaning procedures" (core questions for monitoring wash in healthcare facilities in the sdg). "housekeeping refers to the general cleaning of hospitals and clinics, including the floors, walls, certain types of equipment, furniture, and other surfaces. cleaning entails removing dust, soil, and contaminants on environmental surfaces. cleaning helps eliminate microorganisms that could come in contact with patients, visitors, staff, and the community; and it ensures a clean and healthy hospital environment for patients and staff." (national infection and prevention and control guidelines for health care services, 2010) environmental cleaning is a major challenge due to financial constraints: "as a result, health facilities often lack funds for capital infrastructure investments and ongoing operation and maintenance as well as for overlooked functions such as cleaning and waste management" (wash in hcf, practical steps to achieving quality care). the constitution of kenya indicted the right to a clean environment by all citizens but does not specifically address healthcare facilities. "every person has the right to a clean and healthy environment, which includes the right-f(a) to have the environment protected for the benefit of present and future generations through legislative and other measures, particularly those contemplated in article 69" (kenya constitution). the importance of wash in connection to achieving sdg3 was highlighted in some of the documents: "noting that without sufficient and safe water, sanitation and hygiene services in health care facilities, countries will not achieve the targets set out in sustainable development goal 3" (a72_r7 wash in healthcare facilities resolutions). specifically, the role of wash in healthcare facilities in achieving quality care as part of the implementing and achieving universal health coverage was mentioned. "in addition, wash in hcf is important for meeting several targets under sdg 3 (health for all) and in particular target 3.8 on universal health coverage" (core questions for monitoring wash in healthcare facilities in the sustainable development goals). universal health coverage was framed to include both financial and quality care. "universal health coverage (uhc) means that all individuals and communities receive the health services they need without suffering financial hardship. it includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care" (wash in hcf, practical steps to achieving quality care). however, the national level documents did not mention universal health coverage in line with wash in healthcare facilities, but did associate uhc with quality care: "other projects include digitization of records and health information system; accelerating the process of equipping of health facilities including infrastructure development; human resources for health development; and initiating mechanisms towards universal health coverage" (kenya health policy 2014-2030). "the goal of devolution in health is to enhance equity in resource allocation and enhance access to essential services by accelerating universal health coverage (uhc) and improving quality service delivery for all kenyans, especially those who need it most" (planning, budgeting performing, review process guide for health sector). the national monitoring tool focused on the registration process of citizens for the uhc and the frequency of visits by patients to a healthcare facility: "what mechanisms are in place to identify those registered for uhc" (final uhc level 2 and 3 final supervision tool). access and functionality of wash in healthcare facilities were associated with infection control in healthcare facilities and beyond: "recalling wha68.7 (2015) on the global action plan on antimicrobial resistance, which underscores the critical importance of safe water, sanitation and hygiene services in community and health care settings for better hygiene and infection prevention measures to limit the development and spread of antimicrobial-resistant infections and to limit the inappropriate use of antimicrobial medicines, ensuring good stewardship" (a72_r7 wash in healthcare facilities resolutions). infection prevention and control in healthcare facilities was defined as: "infection prevention and control (ipc) is broadly defined as the scientific approaches and practical solutions designed to prevent harm caused by infection to patients and health workers associated with delivery of health care" (wash in hcf, practical steps to achieving quality care). kenya has a guide on healthcare infection prevention and prevention: "these guidelines are intended to provide administrators and hcws with the necessary information and procedures to implement ipc core activities effectively within their work environment in order to protect themselves and others from the transmission of infections" (national infection prevention and control guidelines for health care services in kenya, 2010). infection control in healthcare facilities was also associated with waste management: "strengthening infection prevention and control systems including health care waste management in all health facilities" (kenya health act.21 of 2017). wash, infection control and prevention were also associated with the safety of the public, patients, caregivers and healthcare workers: "every patient and every family member and facility staff who cares for them deserves a clean and safe health care environment with high quality water, sanitation, and hygiene services" (wash in hcf, practical steps to achieving quality care). aside focusing on the safety of all who visit health care facilities, some of the documents also highlighted the safety of healthcare workers: "strategies to protect health workers include the following: implementing standard precautions, immunizing all health workers against hbv, especially those working in health care settings, providing ppe, managing exposures in a timely manner, eliminating unnecessary sharps and injections successful implementation of these strategies requires an effective quality improvement or infection prevention and control committee (ipcc) with support from the hospital management team" (national infection prevention and control guidelines for health care services in kenya). some national documents highlight the provision of safe healthcare facilities, but did not link safety to wash nor explain what a safe working environment entail: "the right to a safe working environment that minimizes the risk of disease transmission and injury or damage to the health care personnel or to their clients, families or property" (kenya health act no.21 of 2017). the functionality of wash in healthcare facilities is impacted by climate change or weather patterns or civil disruptions. in the context of the national documents, the increased burden on healthcare facilities was highlighted: "political instability in the eastern africa region and the subsequent in-migration of refugees into kenya has the result of increasing the demand for health services in the country and raising the risk of spreading communicable diseases" (kenya health policy 2014-2030). the need to appropriately site infrastructure was mentioned: "the site should have proper drainage, be located downhill from any wells, free of standing water, and not be in a flood-prone area. the site should not be located on land that will be used for agriculture or development" (national infection prevention and control guidelines for health care services in kenya). the impact of climate change was highlighted, but framed as a question in the washfit tool: "do seasonality and/or climate change affect wash services and are there plans in place to cope with this?" (washfit, a practical guide for improving quality of care through wash in hcfs). measures to reduce or eliminate the impact of climate change, civil disruptions and anthropogenic activities at the healthcare facility were mentioned: "buildings are designed and activities are organized so as to minimize the spread of contamination by the movement of patients, staff and careers, equipment, supplies and contaminated items, including healthcare waste, and to facilitate hygiene" (essential environmental health standards in healthcare). "care must be taken, when siting latrines, to avoid contaminating groundwater and risk of flooding" (essential environmental health standards in healthcare). the national documents mention ddr in light of the general public not specific to the healthcare and wash facilities. healthcare services are needed in times of disasters or disease outbreaks. the importance of wash in healthcare facilities as part of emergency preparedness was highlighted: "wash services strengthen the resilience of health care systems to prevent disease outbreaks, allow effective responses to emergencies (including natural disasters and outbreaks) and bring emergencies under control when they occur" (washfit, a practical guide for improving quality of care through wash in hcfs). the national monitoring tool mentioned emergency preparedness in terms of referral systems, functional emergency teams and the presence of ambulances for patient transportation to referral hospitals: "emergency preparedness and timely response in facility and referral. has there been any referral in the last one month? do you have a functional emergency response team?" (uhc level 2 and 3 final supervision tool). at the county level, the hospital preparedness did not include wash: hospital preparedness. infrastructure-numbers of hospitals with casualty departments, icu, bed capacity, morgue facilities. human resource-well trained cadres (basic life support, advanced cardiac life support.) contingency/response plan updated. disaster emergency kits, medicine stockpiles. community support-alternative treatment centers (health and nutrition sector contingency plan, 2019) wash in healthcare facilities stakeholders emerged in six (6) documents. the implementation of wash in healthcare facilities is a multi-stakeholder activity. at the national level: "however, wash is not the responsibility of the ministry of health alone. ministries of water and sanitation are critical for improving municipal wash supplies and providing technical expertise to health care facilities. ministries of finance can provide important budget allocations and financing mechanisms. moreover, local governments have a responsibility to manage and fund wash at the local level. overall, coordination requires a high level of leadership beyond any one ministry to ensure a common, cohesive approach" (wash in hcf, practical steps to achieving quality care). specifically, quality health care services should be monitored: "the district health management team (dhmt) is responsible for monitoring the facilities within the district for using and complying with ipc practices. the dhmt is also responsible for ensuring that adequate and appropriate resources are available to support ipc practices within these facilities" (national infection prevention and control guidelines for health care services in kenya). other aspects of stakeholder engagement are training, monitoring and evaluation were mentioned. "prepare a budget that reflects aims and available resources, with potential to scale-up. the training budget should realistically consider all the costs, which include the actual training, but also the followup support that is required to assist facilities in ongoing challenges and improvements. in addition, it is useful to consider the funds for physical supplies as even providing some minor, immediate improvements (such as hand hygiene stations, low-cost water filtration or on-site chlorine generation) can help realize major improvements in reducing health risks and set the foundation for longer term improvements such as piped water" (washfit, a practical guide for improving quality of care through wash in hcfs). guided by the political ecology of health theory this paper explored the framing of wash in healthcare facilities in relevant policies, guidelines, legislation, plans, monitoring and evaluation documents at the global and national context using kenya as a case study. in these documents, wash in healthcare facilities was framed in relation to the importance of wash in a healthcare facility such as infection prevention and control, quality care and achieving universal health coverage. it was also framed in terms of infrastructure in healthcare facilities. from a political ecology of health perspective, the global agenda on wash in healthcare facilities influenced the growing concerns of wash in healthcare facilities at the national level in kenya. from this study, the global agenda on achieving the sustainable development goal 3 and goal 6 influenced political, social, economic and cultural factors in the implementation and use of wash in healthcare facilities in kenya. the global resolutions, guidelines and monitoring documents are guides for national level adaption. similarly, with respect to the influence of global campaigns on national agenda, asiki et al. [19] established that the kenya national guidelines on cardiovascular diseases were guided by existing global initiatives and guidelines such as the tobacco control act. specifically, the global campaign on achieving universal health coverage led by the world health organization accelerated movements to implementing universal health coverage in kenya as stated in the kenya health policy (2013-2030). kenya is currently piloting universal health coverage in four counties. the acronym wash means water, sanitation, hygiene, waste management and environmental cleaning [1] . from this research comprehensive mention of wash in healthcare facilities was dominant in global documents than national documents. two national documents mentioned water, sanitation and hygiene in sentences excluding environmental cleaning and waste management. other national documents mentioned one of these components. first, this could be associated with the fact that the global documents addressed wash in health care facilities specifically. none of the national documents were published specifically for wash in healthcare facilities. second, most of the national documents were published before the agenda for wash in healthcare facilities was initiated. in addition, the final monitoring tool for universal health coverage does not comprehensively measure access and functionality of water, sanitation, hygiene, waste management and environmental cleaning. it monitored aspects of water and hygiene. waste management, sanitation and hygiene are in the same category. for instance, the presence of a functional incinerator, a well-protected ash pit, a well-protected placenta pit and having a set of three color-coded bins in all wards and clinical departments and used for segregating waste at the point of generation are in the same category. at the time of data collection, a universal health coverage policy or agenda was not instituted. however, it was evident from the final universal health coverage monitoring tool for the kisumu county that efforts towards the implementation of universal health coverage were directed towards finance and registration of citizens than quality care. indicators for wash in healthcare facilities were not adequately presented and this could have impacts on the planning and financing of quality care when the universal health coverage program is fully rolled out in the country. similarly, maccord et al. [42] highlighted the need for quality data collection on relevant wash in healthcare indicators to achieve environmental health policies in healthcare facilities in their research in malawi. in addition, inadequate or inconsistent data will complicate the assessment of interventions towards implementing universal health coverage [43] . it was also evident that the previous healthcare facility monitoring tool, titled the integrated management supportive supervision tool measured more wash in healthcare indicators than the final universal healthcare monitoring tool measured. although this tool did not comprehensively cover all the aspects of wash, it touched on all five components of wash. for instance, the tool monitored separated toilets for staff and patients. wash in healthcare facilities cannot be achieved without the relevant key stakeholders at both the national and global levels. ensuring access to wash in healthcare facilities is complex and requires the efforts of different institutions. forming partnerships are very critical to achieving complex and connected challenges [44] . the global documents such as the wash resolutions document listed some key institutions, ministry of health, water, finance and energy in achieving wash in healthcare. other relevant key stakeholders include communities where healthcare facilities are situated and nongovernmental organizations. wash in healthcare facilities was also framed in terms of stakeholder engagements such as trainings. training on wash management or infection control, budgeting of funds for implementing wash in healthcare services and monitoring and evaluations are some of the key roles of government and nongovernmental organizations mentioned in both the global and national documents. for instance, inadequate data collection has been associated with lack of technical knowledge on policy documents or monitoring tools by government officials [42] . this barrier hinders advocating for the appropriate resources required for effectively implementing environmental health policies and plans by civil society groups and non-governmental organizations. maina et al. [3] in their research on the role of wash in healthcare facilities in averting anti-microbial resistance in 14 county level hospitals reported inadequate resource allocation by the government as a key challenge to accessing wash in healthcare facilities. similarly, guo & bartram [20] reported that about a fifth of facilities overall 14 countries they investigated as part of a study to explore predictors of water quality in rural healthcare facilities reported having an insufficient budget for supplies for water, sanitation and hygiene or infection control. resources or funding is a major requirement to implementing wash in healthcare facilities [45] . anderson et al. [46] in their paper expressed the need for wash in healthcare facility stakeholders to adequately monitor the quality, quantity, input and output of wash services in healthcare facilities to ensure effective costing when planning for water, sanitation, hygiene, waste management and environmental cleaning in a healthcare facility. it is also recommended that wash national documents in ssa should include relevant stakeholders such as the cleaners and maintenance officers since they directly deal with issues of wash in a healthcare facility [46] . the importance of wash in healthcare facilities cannot be underestimated in terms of infection control and prevention and safety of facility users and workers. cleaning and disinfection of healthcare facilities prevent disease transfer and if not adequately handled weakens the healthcare system. similar to the ebola outbreak, the current covid-19 outbreak has compromised the quality of care in many healthcare facilities and a growing number of healthcare workers have died even in global north countries. however, wash is not listed as a requirement for hospital preparedness in the 2019 county level health and nutrition contingency plan. the issue of wash and safety of patients, caregivers and workers were dominant in global documents than the national documents. the national infection prevention and control guidelines for health care services in kenya clearly lays out the procedures, roles and responsibilities in infection prevention and control at the health care facility. other documents mentioned the need for ensuring a safe working environment for healthcare workers, but do not clearly define what a safe environment means. however, the previous monitoring tool for healthcare facilities monitored the presence of personal protective equipment such as the single use of aprons, goggles, gloves, fire extinguishers and fire exit. the safety and functionality of wash services in healthcare facilities were also framed in the context of natural disasters such as drought and floods. only the health act mentioned issues of wash in healthcare facilities in association with impacts of climate change. wash infrastructure and climate change is also framed as a caution to ensure wash infrastructure are efficient and can withstand and recover from the shocks of climate variability impacts. for instance, engaging in waste burial or burning in a flood prone area facilitates surface and ground water contamination. civil disruptions such as political instability burdens the functionality of healthcare facilities and wash infrastructure in two ways. the structures are often destroyed or the healthcare facilities are burdened with people seeking healthcare. however, these civil disruptions are not mentioned in the global documents in the context of wash in healthcare facilities. kenya has recorded several civil disruptions. of most significance is the post-election violence in 2017. civil disruptions need to be considered in wash in healthcare facility planning, implementation and maintenance. this brings to question the framing of wash and disaster risk reduction in healthcare facilities. disaster risk reduction was framed as a recommendation to healthcare managers. the universal health coverage policy was not available at the time of this study, the authors only had access to the final universal health monitoring tool for level 2 and level 3 facilities. this is a limitation of this study since the authors could not comprehensively analyze the framing of quality care as part of the universal health coverage campaign in the country. however, access to the uhc final monitoring tool highlights the indicators of uhc being prioritized during the piloting phase. this phase is critical to the finalization of the uhc policy in the country. from a policy perspective, there is a need for the development of a national level wash in healthcare facility guideline which addresses contextual factors of kenya across all levels of the healthcare system. all relevant stakeholders should be engaged in the development of a comprehensive binding document on wash in healthcare facilities. this is necessary because research has closely associated the prevalence of disease and poor health management to the lapses in government policies in ghana than other countries [47] . second, the final monitoring tool for universal health coverage needs to be revised to comprehensively measure water, sanitation, hygiene, environmental cleaning and waste management indicators in healthcare facilities using the global tools as guides. it will ensure effective data collection, planning and implementation of wash in hcf. for example, it is evident that integrating washfit training and supervision enhance quality service provision in healthcare facilities [48] . similarly, researchers have contextualized some monitoring tools in wash in hcf research. maina et al. [40] adapted and contextualized the washfit tool and developed washfast for the assessment of wash indicator performance in facilities beyond primary healthcare level. the authors developed a total of 65 wash in healthcare indicators relevant to monitoring wash in hospitals in limited resource areas. in addition, there are existing monitoring tools which can be useful in monitoring wash in hcf indicators. patel et al. [49] review on wash in healthcare monitoring tool developed from 1991 to july 2018 recommended the need for more comprehensive and concrete wash in health care monitoring tools. a recent assessment by the usaid and maternal child survival program on the kenyan health management information systems (hmis) indicated that half of hospitals surveyed used an electronic medical record that was not linked to the district health information software (dhis2) in 2016 [50] . the hmis and the dhis2 could be instrumental in monitoring required wash indicators and quality services should relevant wash indicators be included. from this review, the district health management team (dhmt) is responsible for monitoring all activities in healthcare facilities. access, functionality, safety and availability of water, sanitation, hygiene, environmental cleaning and waste management indicators should be reviewed by the dhmt. effectively monitoring the indicators of wash in hcf will efficiently prepare facilities for disease outbreaks and disasters. in addition, it is evident that kenya has policies, plans and guidelines which when enforced can address the issues of quality healthcare facilities. for instance, the need to include wash infrastructure in healthcare facilities was published in the national infection prevention and control guidelines for healthcare services in kenya in 2010. this is again emphasized in the kenya environmental and sanitation policy, published in 2016. it is evident more needs to be done to ensure policies are fully implemented (42) . commitment by all state officials, nongovernmental organizations and civil society groups are needed to achieve quality care in healthcare facilities. a review of reports on global meeting on wash in healthcare facilities: from resolution to revolution and the wash in health care facilities stakeholder commitments indicated varied levels of commitments. several partners such as non-governmental organizations and private institutions have made commitments to support kenya through global/national/local advocacy, technical support, implementation, research and learning [51] . however, kenya government or country was not listed in the country level commitment section of the report published in 2019 [52] . commitment and prioritization of wash in healthcare facilities by the country's institutions and leaders will accelerate achieving quality healthcare. issues of wash in healthcare facilities should gain equal prominence as issues of financing curative measures in healthcare facilities in the yet to be implemented uhc policy across the country by 2022. in summary, accessing quality healthcare services is a challenge especially in marginalized areas. the lack of access to water, sanitation, hygiene, environmental cleaning and waste management in healthcare facilities affect the quality of care provided. from this research, relevant documents addressing issues of wash in healthcare facilities, quality health services and universal health coverage at the global and national levels framed wash in healthcare facilities in terms of its importance, like infection prevention and control and enhancing universal health coverage and types of infrastructure. factors such as climate change and civil disruptions that affect the access and use of wash in healthcare facilities were also highlighted and framed as precautions to healthcare managers. however, the national document did comprehensively covered issues of water, sanitation, hygiene, waste management and environmental cleaning. in addition, the global guidelines at the national level are not comprehensively implemented which will lead to recurrent insufficient data on wash in healthcare planning. the influence from the global level on universal health coverage implementation at the local level is positive, but efforts at the national level were directed at the number of citizens registering and medication supply. efforts should also be directed towards ensuring healthcare facilities have the appropriate infrastructure for infection control and safety of healthcare facility users. ensuring good health through providing care as stated in sdg 3 cannot be achieved without efforts to achieve wash, sdg 6 at a healthcare facility. environmental conditions in health care facilities in low-and middle-income countries: coverage and inequalities evaluating the foundations that help avert antimicrobial resistance: performance of essential water sanitation and hygiene functions in hospitals and requirements for action in kenya wash and gender in health care facilities: the uncharted territory. health care women int who delivers without water? a multi country analysis of water and sanitation in the childbirth environment sub-saharan africa multispeed growth revisiting the history, concepts and typologies of community management for rural drinking water supply in india monitoring as a focus for community engagement in water management in aotearoa-new zealand flash appeal sanitation, and hygiene in health care facilities in low-and middle-income countries and way forward; world health organization health-system resilience: reflections on the ebola crisis in western africa lessons from the domestic ebola response: improving health care system resilience to high consequence infectious diseases the link between the west african ebola outbreak and health systems in guinea, liberia and sierra leone: a systematic review sendai framework for disaster risk reduction world health organization. water, sanitation and hygiene in health care facilities: practical steps to achieve universal access; world health organization social science & medicine 50 years of medical health geography (ies) of health and wellbeing old ideas, new ideas or new determinisms? prog. hum. geogr. 2017 urban water supply in sub-saharan africa: historical and emerging policies and institutional arrangements policy environment for prevention, control and management of cardiovascular diseases in primary health care in kenya predictors of water quality in rural healthcare facilities in 14 low-and middle-income countries challenges to changing health behaviours in developing countries: a critical overview geographies of health: an introduction methods for the scientific study of discrimination and health: an ecosocial approach political ecologies of health the political ecology of disease as one new focus for medical geography devolopment: the past, present and future contributions of health geography. in the routledge handbook of health geography inherited burden of disease: agricultural dams and the persistence of bloody urine (schistosomiasis hematobium) in the upper east region of ghana the place of health and the health of place: dengue fever and urban governance in putrajaya, malaysia. health place the political ecology of health: perceptions of environment, economy, health and well-being among 'namgis first nation one community's journey to lobby for water in an environment of privatized water: is usoma too poor for the pro-poor program? afr refocusing on quality of care and increasing demand for services; essential elements in attaining universal health coverage in kenya; ministry of health acceptability and use of portable drinking water and hand washing stations in health care facilities and their impact on patient hygiene practices, western kenya infrastructural challenges to better health in maternity facilities in rural kenya: community and healthworker perceptions everyone is exhausted and frustrated': exploring psychosocial impacts of the lack of access to safe water and adequate sanitation in usoma the stuff that dreams are made of: hiv-positive adolescents' aspirations for development doing' health policy analysis: methodological and conceptual reflections and challenges. health policy plan review article reforming the health sector in developing countries: the central role of policy analysis. health policy plan a conceptual evaluation framework for the water and sanitation for health facility improvement tool (wash fit) extending the use of the world health organisations' water sanitation and hygiene assessment tool for surveys in hospitals-from wash-fit to wash-fast debating an emerging paradigm the implementation of environmental health policies in health care facilities: the case of malawi the sustainable development goal on water and sanitation: learning from the millennium development goals nexus thinking in current eu policies-the interdependencies among food, energy and water resources case study of water, sanitation, and hygiene (wash) in healthcare facilities in ethiopia and keya: key findings and recommendations budgeting for environmental health services in healthcare facilities: a ten-step model for planning and costing health & place hepatitis b in ghana's upper west region: a hidden epidemic in need of national policy attention strengthening healthcare facilities through water, sanitation, and hygiene (wash) improvements: a pilot evaluation of wash fit in togo assessment of water, sanitation and hygiene in hcfs: which tool to follow? management information systems (hmis) review: survey on data availability in electronic systems for maternal and newborn health indicators in 24 usaid priority countries wash in health care facilities; from resolution to revolution sanitation, and hygiene in healthcare facilities we are grateful to festus ogada, medical officer of health, kisumu east sub county, department of water and sanitation, ministry of health, kisumu county and cohesu, kenya for their contribution to this research during data collection. the authors declare no conflicts of interest. key: cord-318063-bainw3d6 authors: haque, mainul; sartelli, massimo; mckimm, judy; abu bakar, muhamad title: health care-associated infections – an overview date: 2018-11-15 journal: infect drug resist doi: 10.2147/idr.s177247 sha: doc_id: 318063 cord_uid: bainw3d6 health care-associated infections (hcais) are infections that occur while receiving health care, developed in a hospital or other health care facility that first appear 48 hours or more after hospital admission, or within 30 days after having received health care. multiple studies indicate that the common types of adverse events affecting hospitalized patients are adverse drug events, hcais, and surgical complications. the us center for disease control and prevention identifies that nearly 1.7 million hospitalized patients annually acquire hcais while being treated for other health issues and that more than 98,000 patients (one in 17) die due to these. several studies suggest that simple infection-control procedures such as cleaning hands with an alcohol-based hand rub can help prevent hcais and save lives, reduce morbidity, and minimize health care costs. routine educational interventions for health care professionals can help change their hand-washing practices to prevent the spread of infection. in support of this, the who has produced guidelines to promote hand-washing practices among member countries. health care-associated infections (hcais) are those infections that patients acquire while receiving health care. 1 the term hcais initially referred to those infections linked with admission to an acute-care hospital (earlier called nosocomial infections), but the term now includes infections developed in various settings where patients obtain health care (eg, long-term care, family medicine clinics, home care, and ambulatory care). hcais are infections that first appear 48 hours or more after hospitalization or within 30 days after having received health care. 2 multiple studies indicate that the most common types of adverse events affecting hospitalized patients are adverse drug events, hcais, and surgical complications. [3] [4] [5] [6] [7] the us center for disease control and prevention identifies that nearly 1.7 million hospitalized patients annually acquire hcais while being treated for other health issues and that more than 98,000 of these patients (one in 17) die due to hcais. 8 the agency for health care research and quality reported that hcais are the most common complications of hospital care and one of the top 10 leading causes of death in the usa. 9 out of every 100 hospitalized patients, seven patients in advanced countries and ten patients in emerging countries acquire an hcai. 10 other studies conducted in high-income countries found that 5%-15% of the hospitalized patients acquire hcais which can affect from 9% to 37% of those admitted to intensive care units (icus). 11, 12 multiple research studies report that in europe hospital-wide prevalence rates of hcais range from 4.6% to 9.3%. [13] [14] [15] [16] [17] [18] [19] [20] [21] the who reports however that hcais usually receive public attention only when there are epidemics. 22 hcais also have impact on critically ill patients with around 0.5 million episodes of hcais being diagnosed every year in icus alone. 7, 14, 23 icu patients are often in a very critically ill, immuno-compromised status which increases their susceptibility to hcais. 24, 25 brief history there has been long-standing awareness that the practice of medicine can do harm as well as good. for example, hippocrates, the father of modern medicine, stated more than 2,500 years ago that "i will use treatments for the benefit of the ill in accordance with my ability and my judgment, but from what is to their harm and injustice i will keep them." 26 it was also recognized (eg, by semmelweis discussing puerperal fever) many years ago that coming into hospitals (in particular) can be dangerous. 27 in this century, the idea that medicine could cause harm, including death is described as "unintended physical injury resulting from or contributed to by medical care, including … [its] absence … that requires additional monitoring, treatment or hospitalization, or … results in death." 28, 29 offering another perspective, an american natural sciences writer noted that hcais are now killing around 100,000 people, many more than hiv/aids, cancer, or road traffic accidents. 30 the hungarian obstetrician professor (dr) ignaz phillip semmelweis is largely considered as the medical doctor who realized that health care providers could communicate disease. his work identified the mode of communication and spread of puerperal sepsis while working at the maternity hospital in vienna. in 1847, he observed higher rates of maternal mortality among patients treated by obstetricians and medical students than among those cared for by midwives. at that time, he also found that a pathologist had died of sepsis after wounding himself with a scalpel while carrying out an autopsy on a patient with puerperal sepsis. the pathologist's illness mirrored that of women with puerperal sepsis, and semmelweis wrote that both a scalpel and a physicians' contaminated hands could transmit organisms to mothers during labor. he introduced chlorinated lime hand washing to the obstetric hospital staff, resulting in large improvements in maternal mortality rates. 31 however, semmelweis' theories were dismissed by most of the medical establishment because of a lack of appropriate statistical analysis of the data. nevertheless, after koch's postulates were published in 1890, the germ theory of disease and semmelweis' theory of transmission of disease from doctor to patient were found to be valid. semmelweis was therefore the first to describe an hcai and provide an intervention to avert its spread through hand hygiene. 32 a survey conducted in 183 us hospitals with 11,282 patients reported that 4% of patients had at least one hcai with the most common microorganism being clostridium difficile. most infections were surgical site infections (ssis), pneumonia, and gastrointestinal infections. 33 a study 2 years earlier by the same group found that 6% (51) of patients had suffered from hcais with the top 75.8% acquiring ssis, urinary tract infections (utis), pneumonia, and bloodstream infections. staphylococcus aureus was the most frequently detected microorganism. 34 the group conducted a comparative study between 2011 and 2015 and found a statistically significant (p<0.05) reduction of hcais in ssis, utis, and central line infections, probably due to a national initiative. 35 hcais are also problematic elsewhere in the world. for example, a study in singapore reported 11.9% (646) patients with hcais, primarily undetermined clinical sepsis, and pneumonia caused mainly by s. aureus and pseudomonas aeruginosa. 36 this study also reported that the acinetobacter species and p. aeruginosa were extremely resistant to carbapenem. 36 a recent european study found that 2,609,911 new patients were identified as having hcais annually in the european union and european economic area. 37 this study revealed that for every 20 patients hospitalized, at least one acquired an hcai which was preventable. 37 klebsiella pneumoniae and the acinetobacter species were exceedingly resistant to multiple antimicrobials, and the lack of new antimicrobials increases the huge burden in europe. 37 in greece, the hcai prevalence rate was 9.1%. the frequent types of hcais were lower respiratory tract infections (lrtis), bloodstream infections, utis, ssis, and systemic infections. 38 one systematic review and meta-analysis regarding hcais in southeast asian countries (brunei, myanmar, cambodia, east timor, indonesia, laos, malaysia, the philippines, singapore, thailand, and vietnam) found an overall prevalence rate of 9.1% with the most common microorganisms being p. aeruginosa, the klebsiella species, and acinetobacter baumannii. 39 a study conducted in eight university hospitals of iran (ranging from 60 to 700 beds) reported an overall hcai frequency of 9.4%, the most common hcais were bloodstream infections, ssis, utis, and pneumonia. 40 19-4.28) . being admitted to an icu is not in itself a self-determining hcai risk factor. the or for all hcais of acquiring an infection was 3.24 (95% ci 2. 34-4.47) in patients with hospital stays longer than 8 days. 33 seventy-one percentage (71%) of the studied patients received antimicrobials, but 9.4% had at least one evidence of infection. 33 another study revealed that the average number of microbes ranged from on (9.67×1011), working surfaces (1.64×1012), door handles (1.71×1012), and highest in taps (2.08×1012). 41 the highest number (23) of pathogens were isolated from door handles, and the peak variance of pathogens were on hospital floors (7). among those microbes, those that were disease-producing were 46.14%, 53.86% were nonpathogenic, the most common was s. aureus at 14.42% and 45.2% of the total bacterial isolates comprised bacillus subtilis. a study conducted in ghana reported that gentamicin was the most effective antibiotic (100%) on both gram-positive and gram-negative organisms, but of the 12 antibiotics tested (ampicillin, cefuroxime, cotrimoxazole, cefotaxime, tetracycline, amikacin, gentamicin, chloramphenicol, cefixime, cloxacillin, and erythromycin), six were resistant to either gram-positive or gram-negative organisms. 41 most of the hcais in the us are triggered by the eskape group, comprising the antimicrobial-resistant gram-negative microorganisms (k. pneumoniae, a. baumannii, p. aeruginosa, and enterobacter spp.) and the grampositive species, enterococcus faecium and s. aureus. [42] [43] [44] multiple studies report that gram-negative organisms are responsible for 10%, 45 20%-40%, 46 of hcais and that antimicrobial resistance places a significant burden on the global health care system, particularly in low resource countries. 47, 48 this problem is exacerbated as research and development into new antimicrobials targeting gram-negative organisms has rapidly decreased in recent years. 48 among the newer aminoglycosides, plazomicin has been found to be active against the extended-spectrum betalactamase (esbl) generating strains of enterobacter spp., escherichia coli, and k. pneumoniae 49 and more effective in laboratory experiments against a. baumannii than gentamicin, tobramycin, and amikacin. 50 plazomicin has a better safety profile than other drugs, with no report of damage to the cochlea, auditory nerve, vestibular, and renal system in healthy volunteers, even with high and multiple doses. 51 another study found that, in a comparison between hcais due to methicillin-sensitive s. aureus and methicillin-resistant s. aureus (mrsa), isolates were statistically significantly (p<0.005) more resistant to ciprofloxacin, clindamycin, trimethoprim/sulfamethoxazole, erythromycin, gentamicin, and tetracycline. 52 hospital waste, especially contaminated surgical waste, often acts as a reservoir for pathogenic virulent microorganisms, and it suggested that 20%-25% of the waste produced by health care outlets is considered to have high potential to cause hcais, it therefore needs appropriate handling and disposal. 53 45, 55 some of these gram-negative microorganisms have a much higher rate (20%-40%) of resistance than others 45 with the organisms isolated from device-associated hcais having the highest antimicrobial resistance phenotypes. 56 in the latter study, although similar to the percentage resistance for most phenotypes was that in an earlier research study, 45 an upsurge in the scale of the resistance fractions against e. coli pathogens was observed, especially with fluoroquinolones. 56 acinetobacter, burkholderia spp. and pseudomonas spp. isolates were 100% were 92% resistant to cephalosporins respectively. burkholderia spp. was again totally resistant to fluoroquinolones and acinetobacter spp. and pseudomonas spp. were 94.2% and 95.8% resistant, respectively. the same study reported that 86.4% acinetobacter spp. and 62.5% pseudomonas spp. showed a high resistance to carbapenems, the preferred drug regime in icus. carbapenems were found more effective against burkholderia spp. with 20% resistance. 57 in another study, enterobacteriaceae community were found to be completely resistant to third-generation cephalosporins. 58 over 80% of the klebsiella spp. community were resistant to ciprofloxacin, gentamicin, piperacillin, tazobactam, and imipenem showing 48.6% resistance. e. coli was equally resistant although carbapenems were effective in almost haque et al 80% cases. although citrobacter spp.-related hcais are a relatively minor proportion, they also show resistance toward cephalosporins, fluoroquinolones, and aminoglycosides. 58 another study reported that although the acinetobacter spp. were 76.99%-92.01%, resistant to most antimicrobials, only 30% of acinetobacter spp. isolated were susceptible. 59 it can be seen therefore that the causative pathogenic microorganisms differ from country to country as does patterns of resistance. alongside infections due to cross-contamination between patients and health workers, patients being susceptible to common infections due to diminished immune responses, and infections at surgery sites (ssis), many hcais are due to implants and prostheses. these include central line-associated bloodstream infections (clabsis), catheter-associated utis, and ventilator-associated pneumonia (vap). 57, 60, 61 clabsis clabsis substantially increase morbidity, mortality, and health care costs, and great attention has been paid to addressing these. 62, 63 as a consequence, in 2009, 25,000 fewer clabsis occurred in the icus of us hospitals than in 2001, a 58% reduction, with about 6,000 lives saved and estimated financial savings of us$414 million in potential excess health care costs, although the costs of reducing such infections is very high. 64 it is estimated that it costs ~$1.8 billion between 2001 and 2009 to save an additional 27,000 lives. 64 despite this investment, a considerable number of clabsis still occur, especially in outpatient hemodialysis centers and inpatient wards. 64 another study also reported the link between clabsis and considerable morbidity and mortality, although there is a wide variation in reported infection rates (from 20% to 62.5%) in emerging economies. 65 a study conducted in taiwan reported the occurrence of clabsis as 3.93 per 1,000 central-catheter days. 66 the most common causative pathogens were gram-negative (39.2%), gram-positive (33.2%), and candida spp. microorganisms (27.6%). 66 in this study, patients developed clabsis 8 days from the time of insertion of the central line catheter. 66 multivariate analysis showed that a higher pitt bacteremia score (or 1.41; 95% cl=1.18-1.68) and the prolonged interval between the onset of clabsis and catheter removal (or 1.10; 95% ci=1.02-1.20) were associated with higher death rates. 66 another similar study identified prolonged catheter in situ, pediatric icu stay, and intravenous nutrition were significant prognosticators of peripherally inserted central catheter-related clabsis among hospitalized children. 67 ssis ssis (formerly termed "wound infections") are still one of the most common adverse events that occur in hospitalized patients undergoing surgery or in outpatient surgical measures, regardless of the advances in preventive procedures. 68 ssi is the most common complication in postoperative surgical patients, associated with significant morbidity, high death rates, and financial stress on national budgets and individual patients. [69] [70] [71] ssis are defined as infections arising up to 30-90 days after surgery in patients receiving an organ, group of cells, or device and affecting both the incisional site and deeper tissues around the surgery location. 72, 73 the type of surgery determines the proportion of ssis. between 2% and 36% of patients may develop ssis, with the highest risk for orthopedic followed by cardiac and intraabdominal surgery. 14, 72, 74, 75 the length of hospital stay for patients with ssis increases from 4 to 32 days as compared with patients with no post-surgical infections. [76] [77] [78] approximately 25% of patients with ssis develop severe sepsis and shock and are moved to an icu. 65 ssis cause statistically significant morbidity, mortality, and financial burdens for individuals and for communities. [69] [70] [71] 78 hcais are common following cardiac surgery, with a reported incidence rate of between 5.0% and 21.7%, 79, 80 often accompanied with multiple organ failure and prolonged hospital stays, leading to increased mortality rates. 79, 80 the three most common locations for hcais after cardiac surgery are lungs, central venous catheters, and surgical sites. 69 ssis followed by cardiac surgery classically present with localized cellulitis (erythema, warmth, and tenderness), purulent discharge, sternal instability, chest pain, and systemic upset with deep infections. [81] [82] [83] ssis are devastating for orthopedic patients as it is very difficult to rid the bones and joints of the infection. 83 one saudi arabian study reported an incidence of ssis in orthopedic patients of 2.55% (79 of 3,096 patients) with the most common pathogens being staphylococcus species including mrsa (29.11%); acinetobacter species (21.5%); pseudomonas species (18.9%), and enterococcus species (17.7%). 84 surgical wound contamination potentials, patients' clinical conditions, type of surgery, and length of surgery were variables statistically significantly associated with ssis and should be viewed as risk factors. 85 the movement and number of staff and the structural features of the operating theater also affect the incidence of ssis. 85, 86 one study found that 73.33% cases of ssis following orthopedic surgery were culture positive, and a total of 35 bacterial strains were isolated, among which 65.72% were grampositive isolates and 34.28% were gram-negative bacteria. 87 infection and drug resistance 2018:11 submit your manuscript | www.dovepress.com health care-associated infections and prevention strategy about 68.6% of all bacterial isolates were resistant to cefuroxime used in the management of orthopedic ssis. this study also found that diabetes mellitus, smoking, operations lasting more than 3 hours, the absence of antibiotic prophylaxis, and a history of previous surgery were positive risk factors associated with a significant upsurge in ssis. 87 ssis comprise at least 14%-22.2% of all hcais for abdominal surgery [88] [89] [90] and often lead to extended hospitalization and higher antimicrobial costs. 71 the microorganisms generally involved in such ssis include s. aureus, coagulasenegative staphylococci and enterococcus spp., and e. coli. 71 s. aureus has been known to be a major cause of hcais for over 100 years. 91 when first introduced, nearly all strains were susceptible to penicillin, but since its wide and often irrational use, s. aureus started to become resistant by producing β-lactamase enzyme. 91 by 1960, 95% hospital variants of s. aureus were resistant. 91, 92 to help combat resistance, several new penicillins were developed to resist staphylococcal β-lactamase, such as methicillin, oxacillin, cloxacillin, and flucloxacillin. 91 however, within 1 year of methicillin being marketed in 1960, the first mrsa strain of s. aureus was reported in england. 93 the mrsa strain represents 50% of hcais in the us and europe and causes infections that are very difficult to manage because of their potential resistance to multiple antimicrobials. [94] [95] [96] in one study, the incidence of ssis was after gastrectomy in 11.3%, after colorectal surgery in 15.5%, after hepatectomy in 11.3%, and after pancreaticoduodenectomy in 36.9%. 97 while the incidence of ssis was higher in the absorbable stitching material than the silk group for all surgical procedures, the difference was not statistically significant. 97 a japanese study on abdominal surgery reported an overall ssi rate of 14.4%. the ssi rates in the suture-less, vicryl, and silk groups were 4.8%, 14.8%, and 16.4%, 88 respectively, again with no statistically significant differences between the groups. in colorectal surgery, the ssi rate in the polyglactin 910 (absorbable, synthetic, usually braided suture; vicryl tm ) group was 13.9%, which was statistically significantly lower than that of the silk group (22.4%; p=0.034). the incidence of deeper ssis in the vicryl group, including deep incisional ssis (issis) and organ/space ssis (osis), was statistically significantly lower than that in the silk group (p=0.04). 88 the ssi rates did not differ among the suture types overall in gastric surgery or in appendectomy. 98 a us study of pediatric patients found that while this was only 2.5% of the caseload, colorectal surgery contributed to 7.1% of the ssis. 98 the ssi rates of all types of colorectal surgery were 5.9% (issis: 3.2%; osis: 2.7%) with the uppermost being total abdominal colectomy (11.4%) trailed by partial colectomy (8.3%) and colostomy closure (5.0%). 98 inflammatory bowel diseases caused the topmost health problems in a comparison of all colorectal diagnosed diseases (24.9%; issis: 22%; osis: 28.6%). hirschsprung's disease (14.2%; issis: 15.4%; osis: 12.8%) and anorectal malformations (12.4%; issis: 17.6%; osis: 6.4%) were the next major group in colorectal diseases. 98 finally, a study utilizing univariate analysis defined 13 statistically significantly variables related to ssis. those were patients aged over 60 years, lower functional status, diabetes mellitus, congestive heart failure, immunocompromising disease, anticancer medications, immunosuppressive agents, impaired immune system, open cholecystectomy, laparotomy, an american society of anesthesiologists score above 2, drain insertion, and dirty wound. 99 using multivariate regression analysis, this study also found that immunosuppressive agents (or =2. 5 internationally, utis are the most common hcais and one of the top ranking microbial infections, representing around 40% of hcais, with significant consequences for morbidity and mortality and substantial financial implications. 14, 99, 100 although cautis are typically benign, some patients have potentially pathogenic virulent bacteria but are asymptomatic, and these patients were associated with a three-times higher mortality than in non-bacteriuric patients. 101, 102 multivariate analysis indicates the risk factors for cautis including prolonging the duration of the catheter, female sex, older age, diabetes mellitus, the absence of systemic antibiotics, catheter insertion outside the operating room, and a breach in the closed system of catheter drainage. 101, 103 the rate of cau-tis has been estimated to be about 5% per day, regardless of the duration of the indwelling catheter, with e. coli being the main infecting pathogenic microorganism, although a wide spectrum of other microorganisms were identified, including eukaryotic fungus. 104, 105 the repetitive inappropriate administration of antimicrobials often leads to greater bacterial resistance. cautis habitually lead to biofilm formation on both the extraluminal and intraluminal portal catheter surface, largely from extraluminal microorganisms. [106] [107] [108] the biofilm defends microbes from both antimicrobials and host defense mechanisms. 109 haque et al inserted and cleaned, in patients with long-term indwelling catheters, fever from cautis is common with a frequency fluctuating from one per 100 to one per 1,000 catheter days. 105 patients in institutional care with long-term indwelling catheters have a greater risk for the presence of pathogenic microorganisms and other urinary tract diseases than those without catheters. 105 one meta-analysis found that cautis were linked with statistically significantly higher death rates (or =1.99; 95% ci =1.72-2.31; p<0.00001; i 2 =54%; eight studies; 62,063 patients) and days in the icu (weighted mean difference of +12 days; 95% ci =9-15; p<0.00001; i 2 =96%; seven studies; 13,011 patients) and hospital (mean difference +21 days; 95% ci =11-32; p<0.0001; i 2 =98%; five studies; 10,183 patients). 110 an australian health care-associated urinary tract infection (hcauti) non-concurrent cohort study carried out for 4 consecutive years found that patients had an extra 4 days (95% ci =3.1-5.0 days) of hospitalization. 111 this study further reported that the infection rate was statistically significantly minimized utilizing a cox regression model (hr =0.78; 95% ci =0.73-0.83) when patients were released from the hospital. 111 hcautis very rarely cause death (hr =0.71; 95%ci =0.66-0.75), especially in large hospitals when compared to other health care institutes, even when compared with age and sex (hr =0.74; 95% ci =0.69-0.78), although elderly patients more often died (hr =1.40; 95% ci =1.38-1.43). 111 vap the death risk for patients in the icu is not only because of their original illness but often because of hcais. 2, 54, 112 pneumonia is the second commonest hcai in icus, affecting more than one-quarter of patients. 113, 114 around 86% of hcais are associated with motorized automatic ventilation and vap. 113 between 9% and 27% of patients with assisted ventilation develop this kind of pneumonia, and vap has been identified internationally as a potential major cause of death. 114 the average critical time to develop vap following endotracheal intubation and mechanical ventilation was 2-3 days. 115 patients usually develop a fever, altered bronchial sounds, white blood cell counts reduced, changes in sputum, and causative organisms are often identified. [116] [117] [118] [119] [120] [121] a us study found a range of vap of between 1.2 and 8.5 per 1,000 ventilator days 122 although an international group reported a much higher occurrence of vap of 13.6/1,000 ventilator days. 123 in asian countries, a different picture of 3.5-46 infections/1,000 ventilator days emerges, 124 with a very high incidence rate in india of 40.1 per 1,000 ventilator days. 125 the initial 5 days of mechanical ventilation is the most critical time for the development of vap, with a mean duration of 3.3 days between intubation and the development of vap. [119] [120] [121] [122] [123] [124] [125] [126] another recent indian study reported that non-fermentative gram-negative bacilli 127 were the predominant organisms, followed by pseudomonas and klebsiella genus. in this study, s. aureus reduced in prevalence from 50% to 34.9% between 2011 and 2013, but between 2012 and 2013 vancomycin-resistant enterococci increased from 4.3% to 8.3%, while methicillin resistance among s. aureus exceeded 50% in 2013. in addition, an upwavard trend in resistance by pseudomonas genus was observed for piperacillin-tazobactam, amikacin, and imipenem. the incidence of non-fermenters' resistance continued to be very high except for amikacin and imipenem (33.1%) and polymyxin-b (2.4%). 127 a study at chonnam national university hospital in south korea of the transtracheal aspirates or bronchoalveolar lavage of patients suffering from vap found that s. aureus (44%) was the most frequently detected causative microorganism followed by a. baumannii (30%), p. aeruginosa (12%), stenotrophomonas maltophilia (7%), k. pneumoniae (6%), and serratia marcescens (2%). 128 in addition, s. aureus was found as mrsa and 69% of acinetobacter baumannii were imipenem-resistant. 128 no statistically significant variance was observed in the imipenem-resistant a. baumannii 128 between the earlier and late vap-related study groups (73% [8/11] vs 67% [14/21] , p=1.000). 128 in this study, 67% of k. pneumoniae was esbl-positive. 128 vap was frequently linked with substantially increased morbidity, including prolonged icu and hospitalization, and higher ventilator days and health care costs. 129 in the uk and the republic of ireland, a european study of hcais connected with respiratory infection found a prevalence rate of 7.59%. among these hcais, 15.7% were pneumonia, and 7% were lower respiratory tract infections other than pneumonia (lrtiop). 130 around 21% of patients in both the groups were having artificial ventilation, which was much higher when compared to the rest of the patients with hcais. mrsa was the principal invading microorganism for both pneumonia and lrtiop. although the patients with lrtiop suffered more from c. difficileinduced diarrhea than pneumonia, this was not statistically significant. 130 a recent chinese study reported that 14.94% (895) of inpatients acquired a lrti which prolonged their hospital stay and increased the costs per individual case by us$2,853.93. 131 another study revealed that 9.6% of patients developed hcais, of which respiratory tract infections were the highest at 65.8%. 132 the most frequently identified respiratory pathogen was gram-negative acinetobacter species (40.4%), and among these 21% were mdr. 132 submit your manuscript | www.dovepress.com health care-associated infections and prevention strategy a significant number of patients develop pneumonia after surgery which includes both hospital-acquired pneumonia (pneumonia developing 48-72 hours after admission) and (as discussed above) vap (pneumonia developing 48-72 hours after endotracheal intubation). 133 postoperative pneumonia has been described as one of the leading consequences of all types of surgery with a high incidence of morbidity and mortality. 134 it increases hospital stays on an average of 7-9 days and increases health care costs from us$12,000 to us$40,000. 114, 135, 136 hcais hcais are a major safety concern for both health care providers and patients. they continue to escalate at an alarming rate, especially in emerging economies, with infection rates 3-20 times higher than in high-income countries. 1, 2, 137 hcais increase morbidity, mortality, length of hospital stays, and costs; 138-140 therefore, more research and changes in practice are needed to ensure hospital safety and prevent hcais. 32, [141] [142] [143] the annual costs for hcais alone in the usa are between us$28 and us$45 billion, but with even this amount of spending, 90,000 lives are still lost per year: hcais are among the top five killers in the usa. 14, [144] [145] [146] [147] the who advocates that effective hand hygiene is the single most important practice to prevent and control hcais, which form colonies with mdr microbes. 1, 2, 148, 149 several studies report that a simple and straightforward process, taking only a few seconds to clean hands with an alcohol-based hand rub helps prevent hcais and save lives, reduce morbidity, and minimize health care costs. 150, 151 however, factors such as the availability of alcohol-based hand rubs and up-to-date knowledge of the importance of hand washing hinder good practice in hand hygiene. for example, an australian observational study of community nurses highlighted poor practices of hand hygiene in comparison with a standard protocol. 152 the who promotes and advocates that all health care workers (hcws) must wash their hands before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings. 153 the center for disease control and prevention has developed a comprehensive plan and guidelines for the prevention of hcais which covers basic infection prevention and control (ipc); antibiotic resistance; device-and procedure-associated infections; disease/ organism-specific infections; and guidance for health workers working in specific settings. 154 this guidance, like that of the who and the uk royal college of nursing (rcn) also emphasizes the importance of hand washing. [153] [154] [155] the rcn also promotes and advocates that all health care profes-sionals must receive compulsory "infection control training as part of their induction and on an ongoing annual basis. it is particularly important that knowledge and skills are continually updated." 155 multiple research studies indicate that policy changes and the adoption of novel multifactorial, multimodal, multidisciplinary strategies offer the greatest possibility of success in terms of hand hygiene improvement and the reduction of hcais. [156] [157] [158] [159] [160] [161] [162] [163] [164] [165] [166] [167] instigating best practice in health care stems "from a response to factors that are outside a purely scientific understanding of infection and not simply understood as a deficit in knowledge." 168, 169 good practice for infection prevention among hcws can be ensured through compliance to ipc guidelines. 168 specific individuals acting as "change champions" can act as arbitrators or negotiators, contributing to changing behaviors and implementing best practice to ensure patient safety. [168] [169] [170] [171] this calls for educational interventions that reflect the philosophies, principles, and community understanding of dirt and infection. 169 an educational intervention involving 4,345 health professionals in three public hospitals in the usa successfully improved hand hygiene immensely with the use of alcohol hand rub. nurses, physicians, and allied hcws improved from 14% to 34%, 4.3% to 51%, and 12% to 44%, respectively. 172 other studies also highlight how behavior change around hand washing can result from educational interventions. 149, 151, 172 health professionals must protect themselves with barriers for example, gloves, gowns, face masks, protective eyewear, and face shields, 173 to decrease the work-related transmission of microorganisms. regular use of personal protective equipment (ppe) 173 devices protects both the professional and the patient from potentially infectious body fluids. 173 nevertheless, the use of ppe does not confirm 100% protection, 174 for example, needlestick injury can breach ppe, and, in many occasions, issues might go unrecognized which might cause a dangerous health hazard including hepatitis b or hiv. 175 respiratory microorganisms, for example, influenza virus, bordetella pertussis, haemophilus influenzae, neisseria meningitidis, and mycoplasma pneumoniae, severe acute respiratory syndrome-associated coronavirus, group a streptococcus, adenovirus and rhinovirus, and tubercular bacilli 176 are easily dispersed through droplets (particles ≤5 µm in size) in closed health care settings and often cause endemics and epidemics. 176 [178] [179] [180] [181] [182] meticulous cleaning of hospital surfaces is therefore vital to maintain standards and reduce the risk of hcais. 183 several studies conclude that ultraviolet devices and hydrogen peroxide vapor technologies successfully eradicate potentially dangerous hospital microorganisms adhering to the surfaces in ward or patient rooms. [183] [184] [185] [186] furthermore, hydrogen peroxide vapor efficiently sterilizes and sanitizes all clinical areas where potentially dangerous microbial mdr microorganisms and spores were suspected to be present. 187 in the early to mid-19th centuries in both europe and usa, thousands of young women died from puerperal sepsis and fever, the diseases rampant in the charity maternity clinics of the time 188 and, due to the efforts of (among others) dr ignaz phillip semmelweis and dr oliver wendell holmes, the fight against puerperal fever was won and it was confirmed that hcais were transmitted via the hands of hcws. [188] [189] [190] [191] [192] despite the development of many hi-tech methods, hand washing with soap and water or alcohol rub is still the most important means of maintaining personal hygiene and preventing hcais. 192 however, due to the rise of antibioticresistant bacteria and a reluctance of some hcws to implement best practice infection control, hcais remain one of the biggest causes of death in most countries. therefore, it is essential that strategic, policy, and education initiatives continue to focus on managing and controlling such (predominantly needless) infections. the topic of hcais is a very broad issue, and it has therefore not been possible to cover all aspects of hcais in one paper; hence, we have been selective in selecting key aspects of the current debate. patient safety and quality: an evidence-based handbook for nurses healthcare -associated infections: a public health problem incidence of adverse events and negligence in hospitalized patients: results of the harvard medical practice study i the nature of adverse events in hospitalized patients: results from the harvard medical practice study ii overview of medical errors and adverse events hospitalization in older patients due to adverse drug reactions -the need for a prediction tool reporting of adverse drug events: examination of a hospital incident reporting system estimating health careassociated infections and deaths in u.s. hospitals agency for healthcare research and quality patient safety primers: healthcare-associated infections prevention of healthcareassociated infections: protecting patients, saving lives the global patient safety challenge nosocomial infections in adult intensive-care units multicenter surveillance study for nosocomial infections in major hospitals in korea. nosocomial infection surveillance committee of the korean society for nosocomial infection control health-care associated infections. patient characteristics and influence on the clinical outcome of patients admitted to icu. envin-helics registry data prevalance of and risk factors for hospital-acquired infections in slovenia-results of the first national survey prevalence of nosocomial infections in hospitals in norway prevalence of nosocomial infections in france: results of the nationwide survey in 1996 greek infection control network. prevalence study of hospital-acquired infections in 14 greek hospitals: planning from the local to the national surveillance level multicenter study of the prevalence of nosocomial infections in italian hospitals 11 submit your manuscript | www health care-associated infections and prevention strategy the second national prevalence survey of infection in hospitals--overview of the results the hospital infection standardised surveillance (hiss) programme: analysis of a two-year pilot who. healthcare-associated infections. fact sheet cdc national health report: leading causes of morbidity and mortality and associated behavioral risk and protective factors-united states frailty in the critically ill: a novel concept variables affecting outcome in critically ill patients a guide to the hippocratic oath the art of scientific investigation the science of large-scale change in global health miles to go: an introduction to the 5 million lives campaign brainy quote semmelweis and the aetiology of puerperal sepsis 160 years on: an historical review hospital epidemiology and infection control in acute-care settings emerging infections program healthcare-associated infections and antimicrobial use prevalence survey team. multistate point-prevalence survey of health care-associated infections prevalence of healthcare-associated infections in acute care hospitals in emerging infections program hospital prevalence survey team. reduction in the prevalence of healthcare-associated infections in u. s. acute care hospitals prevalence of healthcare-associated infections and antimicrobial use among adult inpatients in singapore acute-care hospitals: results from the first national point prevalence survey burden of six healthcare-associated infections on european population health: estimating incidence-based disability-adjusted life years through a population prevalence-based modelling study prevalence, incidence burden, and clinical impact of healthcare-associated infections and antimicrobial resistance: a national prevalent cohort study in acute care hospitals in greece the burden of healthcare-associated infections in southeast asia: a systematic literature review and meta-analysis point prevalence and risk factors of hospital acquired infections in a cluster of university-affiliated hospitals in shiraz, iran investigating potential sources of transmission of healthcare-associated infections in a regional hospital mechanisms of antimicrobial resistance in eskape pathogens federal funding for the study of antimicrobial resistance in nosocomial pathogens: no eskape clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the infectious diseases society of america national healthcare safety network (nhsn) team and participating nhsn facilities. antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the national healthcare safety network at the centers for disease control and prevention bad bugs, no drugs: no eskape! an update from the infectious diseases society of america world health organization. the burden of health care-associated infection. in: who guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. chapter 3. geneva: world health organization healthcare-associated infections, infection control and the potential of new antibiotics in development in the usa activity of plazomicin (achn-490) against mdr clinical isolates of klebsiella pneumoniae, escherichia coli, and enterobacter spp antimicrobial activity of a novel aminoglycoside, achn-490, against acinetobacter baumannii and pseudomonas aeruginosa from new york city pharmacokinetics and safety of single and multiple doses of achn-490 injection administered intravenously in healthy subjects healthcare-associated methicillin-resistant staphylococcus aureus: clinical characteristics and antibiotic resistance profile with emphasis on macrolide-lincosamide-streptogramin b resistance health-careassociated infection in africa: a systematic review nosocomial infections: epidemiology, prevention, control and surveillance nhsn annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the national healthcare safety network at the centers for disease control and prevention antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the national healthcare safety network at the centers for disease control and prevention the management and outcome of spinal implant-related infections in pediatric patients: a retrospective review high burden of antimicrobial resistance among gram negative bacteria causing healthcare associated infections in a critical care unit of nepal high prevalence and endemicity of multidrug resistant acinetobacter spp. in intensive care unit of a tertiary care hospital surveillance and prevention of healthcare associated infections clinical and economic outcomes in critically ill patients with nosocomial catheter-related bloodstream infections the clinical and economic consequences of nosocomial central venous catheter-related infection: are antimicrobial catheters useful? department of health & human services central line-associated blood stream infections: characteristics and risk factors for mortality over a 5.5-year period central line-associated bloodstream infections among critically-ill patients in the era of bundle care central line-associated bloodstream infection in hospitalized children with peripherally inserted central venous catheters: extending risk analyses outside the intensive care unit surgical site infections centers for disease control and prevention. national and state healthcare-associated infections progress report is based on 2014 data effectiveness of a hospitalwide educational programme for infection control to reduce the rate of health-care associated infections and related sepsis (alerts)-methods and interim results surgical site infections: epidemiology, microbiology and prevention annual epidemiological report: reporting on 2011 surveillance data and 2012 epidemic intelligence data. ecdc diabetes and risk of surgical site infection: a systematic review and meta-analysis cdc definitions of nosocomial surgical site infections, 1992: a modification of cdc definitions of surgical wound infections excess length of stay attributable to surgical site infection following hip replacement: a nested case-control study length of stay and cost for surgical site infection after abdominal and cardiac surgery in japanese hospitals: multi-center surveillance current preventive measures for healthcare associated surgical site infections: a review frequency, characteristics, and predictors of microbiologically documented nosocomial infections after cardiac surgery the impact of nosocomial infections on patient outcomes following cardiac surgery delayed presentation of deep sternal wound infection deep sternal wound complications: an overview of old and new therapeutic options in-hospital outcomes of delayed sternal closure after open cardiac surgery prevalence of surgical site infection in orthopedic surgery: a 5-year analysis operating theatre quality and prevention of surgical site infections operating room environment and surgical site infections in arthroplasty procedures epidemiology and outcomes of surgical site infections following orthopedic surgery risk factors associated with surgical site infection in upper and lower gastrointestinal surgery surgical site infection surveillance surgical site infections after abdominal surgery: incidence and risk factors. a prospective cohort study the control of methicillin-resistant staphylococcus aureus blood stream infections in england a comparative study on antibiotic resistance of klebsiella strains from surgical and intensive care wards celbenin" -resistant staphylococci methicillin-resistant staphylococcus aureus-associated hospitalizations among the american indian and alaska native population methicillin-resistant staphylococcus aureus in canada: a historical perspective and lessons learned mrsa prevalence in european healthcare settings: a review impact of intra-abdominal absorbable sutures on surgical site infection in gastrointestinal and hepato-biliary-pancreatic surgery: results of a multicenter, randomized, prospective, phase ii clinical trial health care-associated infections and prevention strategy rates and burden of surgical site infections associated with pediatric colorectal surgery: insight from the national surgery quality improvement program epidemiology of urinary tract infections: incidence, morbidity, and economic costs catheter-associated urinary tract infections catheter-associated urinary tract infections: epidemiology, pathogenesis, and prevention catheter associated urinary tract infection: what is it, what causes it and how can we prevent it? a study of risk factors for catheter associated urinary tract infection complicated catheter-associated urinary tract infections due to escherichia coli and proteus mirabilis catheter associated urinary tract infections catheter-related urinary tract infection a prospective study of pathogenesis of catheter-associated urinary tract infections the pathogenesis of catheter-associated urinary tract infection relationship of catheter-associated urinary tract infection to mortality and length of stay in critically ill patients: a systematic review and meta-analysis of observational studies length of stay and mortality associated with healthcare-associated urinary tract infections: a multi-state model performance of critical care prognostic scoring systems in low and middleincome countries: a systematic review nosocomial infections in medical intensive care units in the united states. national nosocomial infections surveillance system ventilator-associated pneumonia hospital-acquired pneumonia: epidemiology, etiology, and treatment ventilator-associated pneumonia: diagnosis, treatment, and prevention ventilator associated pneumonia ventilator-associated tracheobronchitis and pneumonia: thinking outside the box infectious diseases society of america. guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia ventilator-associated pneumonia: diagnosis, treatment, and prevention ventilator-associated pneumonia in the icu a comparison of ventilator-associated pneumonia rates as identified according to the national healthcare safety network and american college of chest physicians criteria inicc members. international nosocomial infection control consortium (inicc) report, data summary for epidemiology, etiology, and diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia in asian countries ventilator-associated pneumonia: a persistent healthcare problem in indian intensive care units! lung india vap outcomes scientific advisory group. epidemiology and outcomes of ventilator-associated pneumonia in a large us database antibiotic resistance & pathogen profile in ventilatorassociated pneumonia in a tertiary care hospital in india bacterial pathogens of ventilator associated pneumonia in a the impact of ventilatorassociated pneumonia on the canadian health care system hospital infection society steering group. four country healthcare-associated infection prevalence survey: pneumonia and lower respiratory tract infections hospital-acquired lower respiratory tract infections among high risk hospitalized patients in a tertiary care teaching hospital in china: an economic burden analysis nosocomial infections in the medical icu: a retrospective study highlighting their prevalence, microbiological profile and impact on icu stay and mortality the epidemiology and risk factors for postoperative pneumonia long-term results of a postoperative pneumonia prevention program for the inpatient surgical ward vap outcomes scientific advisory group. epidemiology and outcomes of ventilator-associated pneumonia in a large us database outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center patient safety and healthcare-associated infection report on the burden of endemic health care-associated infection worldwide the relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs effect of healthcare-acquired infection on length of hospital stay and cost economic burden of healthcare-associated infections: an american perspective funding healthcareassociated infection research: a systematic analysis of uk research investments, 1997-2010 increases in mortality, length of stay, and cost associated with hospital-acquired infections in trauma patients the direct medical costs of healthcare-associated infections in us hospitals and the benefits of prevention five years after to err is human: what have we learned? healthcare-associated infections are associated with insufficient dietary intake: an observational cross-sectional study deaths: leading causes for 1999 hand hygiene barriers faced by health care workers in the gambia: a health belief model approach who global patient safety challenge, world alliance for patient safety. evidence-based model for hand transmission during patient care and the role of improved practices no time for handwashing!? handwashing versus alcoholic rub: can we afford 100% compliance? introducing alcohol-based hand rub for hand hygiene: the critical need for training hand hygiene practices of home visiting community nurses: perceptions, compliance, techniques, and contextual factors of practice using the world health organization's "five moments for hand hygiene my 5 moments for hand hygiene. infection prevention and control healthcare infection control practices advisory committee (hicpac) good practice in infection prevention and control. guidance for nursing staff the relationship between hand hygiene and health careassociated infection: it's complicated a hand hygiene education and training improvement strategy in an acute hospital setting royal college of surgeons in ireland interventions to improve hand hygiene compliance in patient care interventions to improve hand hygiene compliance in patient care the management, prevention, and control of healthcare associated infections in acute nhs trusts in england -international comparison and review national institute for health and care excellence (nice). infection control. quality standards and indicators. briefing paper hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit decreasing hospital-associated rotavirus infection: a multidisciplinary hand hygiene campaign in a children's hospital reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in argentina efficacy of an alcohol/ chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant staphylococcus aureus (mrsa) infection implementing best practice in infection prevention and control. a realist evaluation of the role of intermediaries infection prevention as "a show": a qualitative study of nurses' infection prevention behaviours optimisation of infection prevention and control in acute health care by use of behaviour change: a systematic review my five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene chicago antimicrobial resistance project. effect of education on hand hygiene beliefs and practices: a 5-year program assessment of healthcare professionals' adherence to hand hygiene after alcoholbased hand rub introduction at an intensive care unit in são paulo face shields for infection control: a review statpearls [internet personal protective equipment (ppe) aerobiology and its role in the transmission of infectious diseases committee on personal protective equipment for healthcare personnel to prevent transmission of pandemic influenza and other viral respiratory infections role of hospital surfaces in the transmission of emerging health careassociated pathogens: norovirus, clostridium difficile, and acinetobacter species evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings role of the environment in the transmission of clostridium difficile in health care facilities the role of the surface environment in healthcare-associated infections best practice in healthcare environment decontamination environmental cleaning for the prevention of healthcare-associated infections controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination cleaning hospital room surfaces to prevent health care-associated infections: a technical brief evaluation of hydrogen peroxide vapor for the inactivation of nosocomial pathogens on porous and nonporous surfaces oliver wendell holmes (1809-1894) and ignaz philipp semmelweis (1818-1865): preventing the transmission of puerperal fever 1809-1894) and his essay on puerperal fever historical perspective on hand hygiene in health care. who guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. geneva: who hand hygiene: back to the basics of infection control a short history of midwifery. philadelphia; london: w. b. saunders company the authors are grateful to dr zakirul islam, associate professor and head of the department, pharmacology and therapeutics, eastern medical college, comilla, bangladesh for his cooperation in converting the video abstract from a powerpoint file to video format. the authors report no conflicts of interest in this work. infection and drug resistance is an international, peer-reviewed openaccess journal that focuses on the optimal treatment of infection (bacterial, fungal and viral) and the development and institution of preventive strategies to minimize the development and spread of resistance. the journal is specifically concerned with the epidemiology of antibiotic resistance and the mechanisms of resistance development and diffusion in both hospitals and the community. the manuscript management system is completely online and includes a very quick and fair peerreview system, which is all easy to use. visit http://www.dovepress.com/ testimonials.php to read real quotes from published authors. health care-associated infections and prevention strategy key: cord-033771-yf5aq2h5 authors: lee, sang m.; lee, donhee title: healthcare wearable devices: an analysis of key factors for continuous use intention date: 2020-10-15 journal: serv bus doi: 10.1007/s11628-020-00428-3 sha: doc_id: 33771 cord_uid: yf5aq2h5 this study empirically examined the effects of internal and external factors on actual use behavior, health improvement expectancy, and continuous use intention of healthcare wearable devices. the study proposed a research model with its associated hypotheses that were tested using structural equation modeling. we also performed a comparative analysis of the two sample groups (medical personnel and general public), based on data collected from 288 healthcare wearable devices/apps users. the findings of the study indicated that internal and external factors have positive effects on actual use behavior, and health improvement expectancy and continuous use intention of healthcare wearable devices can be promoted through actual use behavior. the comparative analysis of the two groups showed that medical personnel had higher relationships among the study factors than general public. the study results shed theoretical and practical implications regarding how healthcare wearable devices or apps can be effectively used for disease prevention and health management for the users. with the rapid advances in mobile technology, the use of mobile devices has skyrocketed. it is estimated that more than 70% of the world's population use mobile devices (ericsson 2017) . markets and markets (2017) predicts that the global mobile healthcare market will grow from usd 63.4 billion in 2013 to 90.4 billion in 2022. according to strategy analytics (2019), global smartwatch shipments reached 12.3 million units in june 2019, representing a 44 percent increase from 8.6 million units in june 2018. wearable devices are becoming an increasingly popular platform for healthcare services, particularly given the increasing interest in health, well-being, disease prevention, and fitness, as well as the paradigm shift toward healthcare that is personalized and controlled by individuals (lee 2018) . furthermore, the shift in the medical paradigm, from disease treatment to prevention and health management, has provided the users of wearable devices new experiences that are not available from traditional healthcare-related products and services (lee 2019) . today's digital wearables, converged products of smart sensors, artificial intelligence (ai), the internet of things (iot), big data, robots, and radar technologies, can help manage and prevent diseases. they can measure the heart rate, body temperature, blood pressure, and respiration of the elderly living in homes and facilities, and by detecting their risk indicators, such as worsening disease conditions, falls, and other life-threatening situations (o'donovan et al. 2009; pataranutaporn et al. 2019 ). as such, many companies have developed wearables and smartphone apps to provide a wide range of healthcare services, and this trend is expected to accelerate (braithwaite 2018) . despite the rapid growth of the healthcare wearable devices market, the adoption of these devices and related technologies is diverse as different social segments and countries have varying degrees of socio-technical development (yoon et al. 2020 ). in addition, previous studies on healthcare wearable devices and their applications generally focused on specific age groups (e.g., younger generations), using the technology acceptance model (tam), tam2, unified theory of acceptance and use of technology (utaut), and utaut2 models, or the analysis of technology or market trends (wang et al. 2009 ). there is little empirical research on user acceptance behavior and the actual use of such wearable devices. it is important to identify factors affecting the continuous use intention for healthcare wearable devices. new technologies can increase in value only when they are widely disseminated in the market which induces further product advancements. the diversification of available products helps reduce user burden, especially from a financial standpoint. in addition, the success of healthcare applications is determined by continuous use intention, not just technology acceptance or adoption rates. therefore, it is imperative to examine post-adoption attitudes, such as use intention and its relationship to user characteristics. empirical research on the key factors affecting user acceptance behavior is needed to sustain the use of, and interest in, healthcare applications of wearable devices. there is a paucity of empirical research on the actual use behavior, health improvement expectancy, and continuous use intention of new healthcare devices. this study intends to address the limitations of previous studies by identifying the behavioral differences about healthcare wearables between the two groups: those who are exposed to disease treatment environment (medical personnel) and those who are not (general public). in addition, to differentiate this study from previous ones, its focus will be on disease prevention, by analyzing the actual behavior and continuous use intention. to achieve the research objectives, this study develops a research model based on the knowledge, attitudes, practices, and beliefs (kapb) model, a frequently used method in the development and delivery of health education programs for preventive activities, the utaut2 model related to the acceptance of new technologies, and theory of planned behavior (tpb). this study attempts to answer the following three research questions: (1) do the internal and external activities associated with using a healthcare wearable device impact the actual use behavior of the device? (2) does the actual use of a healthcare wearable device have an impact on the user's health improvement expectancy? (3) does the user's health improvement expectancy (if any) attained by using a healthcare wearable device? a research model is proposed to answer these questions. the results of the study are expected to contribute to both theory and practice regarding the usage of healthcare wearable devices for health improvement and disease prevention. the rest of this paper is organized as follows. in sect. 2, the relevant literature is reviewed. sect. 3 proposes a research model with associated hypotheses. in sect. 4, research methodology and the results of the analysis are presented. we conclude the study in sect. 5 with discussion of the results, implications, limitations of the study, and future research needs. healthcare devices are expected to support not only the growing need for remote medical services without spatial and temporal restrictions but also the increased demand for medical services among senior citizens who suffer from reduced mobility and a lack of access to professional medical services (panner 2019) . there are many factors that influence the expansion of the remote healthcare market like the aging baby boomer generation, the largest age group in the united states, as well as the increasing number of people with chronic diseases such as diabetes and cardiovascular issues (panner 2019) . in addition, the expansion of remote medical services is expected to gain momentum as 5g technology, which became commercially available in 2019, that can expand the location coverage (lee 2019). the current covid-19 pandemic has further highlighted the significance of remote healthcare delivery (chadha et al. 2020; cohen et al. 2020) . wearable technology refers to information technology (it) enabled devices that can be carried on the user's body, such as the wrist, arm, or head (o'donovan et al. 2009; pataranutaporn et al. 2019) . advances in wearable technology and the growing demand from consumers who wish to manage their own health have profoundly influenced the healthcare industry including insurers, providers, and technology companies (phaneuf 2020) . it is expected that the demand for products and services using digital health technology for the aged will continue to expand. such increased demand is also reflected in the accelerating availability of a range of healthcare wearable devices and applications, as well as the increasing number of global digital health startups. with the popularization of smartphone use, applications of wearable technology have exploded, converged with artificial intelligence (ai), iot, and smart sensing. today, they are widely used not only in the healthcare industry but also in gaming, communications, industrial operations, and safety. for example, in healthcare, ibm offers a wide variety of mobile services through its mobile wireless health solutions, and ge healthcare has developed vscan to provide more accurate and faster healthcare services that are not constrained by time and place. wearable devices in healthcare include various forms, including wearable fitness trackers, smart health watches, wearable ecg monitors, wearable blood pressure monitors, and biosensors (phaneuf 2020) . the development of smartphone apps has helped provide a wide range of healthcare services and this trend is expected to accelerate in the future (braithwaite 2018 ). apple's watch 5, galaxy watch active 2 of samsung electronics, fitbit's versa 2, and xiaomi's mi band 4 are good examples. yoon et al. (2020) reviewed current usage areas of wearable devices such as medical (e.g., diagnostic and therapeutic areas), sports, fitness and wellness. the use of wearables as medical devices rather than simple healthcare devices takes various forms (o'donovan et al. 2009; pataranutaporn et al. 2019; yoon et al. 2020) . first, wearable health devices can be accessories, such as a wristwatch. the main function of accessories used by most users is for well-being and fitness. detailed functions include the ability to sync to smartphone applications; store and manage information on key data points, notably the user's psychological status; monitor sleep patterns; track calories burned and consumed; and record distance traveled. second, wearable health devices can be in the form of clothing. smart clothing, which uses computer chips to exchange electrical signals and data, or uses special materials to connect with a smartphone to apply various functions, can measure changes in blood flow, biological rhythm, breathing, and the health of their users and accumulate data (patel et al. 2012; phaneuf 2020; yoon et al. 2020) . third, wearable health devices can be attached to the body. sensimed, a swiss firm, puts a contact lens-type medical device on glaucoma patients to measure their intraocular pressure for 24/7. changes in the intraocular pressure are the most important factor in diagnosing glaucoma, and its progression can be slowed down through continuous monitoring of the intraocular pressure. these contact lenses use sensors and antennas inside the lens to measure the intraocular pressure of the user, transmit and record the data to a smart device in real-time, and store it on the doctor's computer via bluetooth (patel et al. 2012; phaneuf 2020) . fourth, there are biopsy wearables. the most advanced wearables can be transplanted in the user's body or be consumed by users. currently, technologies of this type include ingestible sensors on the patient's medication to ascertain if the medication is being ingested in real-time, and technology that allows a wireless sensor to be implanted on the skin to confirm real-time changes in blood sugar levels for patients who need to be constantly monitored, such as patients with diabetes. the growing demand for healthcare services due to the aging population is fueling the adoption and use of digital health in the care and treatment of elderly citizens (o'donovan et al. 2009; pataranutaporn et al. 2019) . healthcare wearables can also support the remote healthcare sector so that individuals may receive healthcare services without restrictions on time and space. moreover, they hold promise as a solution to such issues as a lack of access to professional medical personnel and for the elderly with limited mobility. gary shapiro, president and ceo of the consumer technology association, stated at the 2018 hearing loss association of america (hlaa) convention in minneapolis that "… the use of personal health devices, such as wireless blood pressure sensors and electrocardiographic sensors, is much more cost-effective and accurate, and a remote patient monitoring system receives real-time patient data and allows doctors to treat patients more effectively compared to when patients visit hospitals" (shapiro 2018) . this suggests that digital healthcare technology can help relieve the intensifying lack of healthcare workers and healthcare facilities caused by the aging population. there is an increasing trend of interest in health monitoring technology and virtual care techniques, which can result in significant cost savings to healthcare institutions and insurance companies (o'donovan et al. 2009 ). thus, the potential for the growth of wearables in the healthcare industry is significant. the global market for healthcare wearable devices is expected to grow at an annual growth rate of 30 percent, from 2.5 billion dollars in 2015 to 12 billion dollars by 2020. despite the explosion of interest in health wearables, there is currently no specific agreement on the research, terminology, and the scope of applications to both well-being and health management. pataranutaporn et al. (2019, p. 3327) suggested that "wearable technology has enabled on-body real-time sensing and computing of human physiological information." phaneuf (2020) reported that wearable technology, including electronic devices in healthcare, is designed to collect data on users' personal health and exercise. phaneuf (2020, p. 1) defined a healthcare wearable technology as "…consumers can wear, like fitbits and smartwatches, and are designed to collect the data of users' personal health and exercise." ravindra (2019, p. 1) defined it as "… that is noninvasive and autonomous, which performs a particular medical function, be it support or monitoring, over a prolonged time period." these definitions of healthcare wearable devices imply that a healthcare wearable device can help prevent disease and review the user's health conditions. in addition, a healthcare wearable device can be attached to the body or combined into a part of the body to enhance and supplement the healthcare capabilities of the human body and be adjusted according to the user's willingness. dunsmuir et al. (2014) defined a healthcare application as the use of smartphone apps and sensors to predict infection or disease to help its users take appropriate actions, and gücin and berk (2015) defined it as an activity that assists healthcare professionals with making medical decisions and providing healthcare education. a healthcare application refers to a task that focuses on shaping consumer health habits, by providing information on such activities as stop smoking, exercise, and diet (aitken and lyle 2015) . to prevent the spread of the covid-19 global pandemic smartphone apps have been effectively used for contact tracing of infected individuals or monitor those in involuntary isolation. the common factor in the studies cited above is that they all explored technology acceptance and use intentions. however, the intention is the will of the individual and may or may not lead to actual behavior to use. as such, there is a need to examine the actual conversion from intention to behavior. since new technologies are to be disseminated in the market, it is also essential to identify factors influencing use intention to examine whether the intention actual resulted in behavior. this study focuses on users who use healthcare applications or devices. consequently, in this study, a healthcare application or device is defined as a mobile-based healthcare application or device used to provide information, measurement, and management of physical and exercise data as well as other healthcare-related content required for personal health management. tam has theoretical foundations on theory of reasoned action (tra) from social psychology (fox and connolly 2018) . to analyze user behavior regarding the acceptance of new technologies, we utilized the two concepts from tam: perceived ease of use and perceived usefulness. specifically, we assumed that when more users feel that a specific system is both easy to use and useful, it would positively influence attitudes toward, and the use intention of, the system (davis et al. 1992) . although tam has been widely used and applied in studies of user intentions and behaviors regarding the acceptance of new technology, it had been noted repeatedly that tam cannot be used to measure actual use intentions. this criticism led to the development of tam2 (venkatesh and davis 2000) . taylor and todd (1995) suggested the decomposed theory of planned behavior (dtpb) based on theory of planned behavior (tpb) and beliefs factors (behavior, normative, and control beliefs) to predict the user's behavioral intention and actual use behavior of a new system. venkatesh et al. (2003) proposed unified theory of acceptance and use of technology (utaut) to ascertain the limitations of tam and tam2 models. utaut is a model that merges multiple theoretical models that can be used to investigate new technology acceptance, including tra, tam, the business motivation model, tpb, the model of pc utilization, innovation diffusion theory, and social cognitive theory (venkatesh et al. 2003 (venkatesh et al. , 2012 ; al-tarawneh 2019). as factors influencing user intention and behavior, utaut included effort expectancy, performance expectancy, social influence, and facilitation condition, as well as voluntariness of use, age, gender, and experience as moderating variables. however, as with tam, utaut was also criticized for not being able to include all the variables related to technology use. therefore, venkatesh et al. (2012) developed utaut2, which includes the three factors of hedonic motivation, price value, and habit. the main difference between utaut and utaut2 is that utaut is a model developed for explaining acceptance intent and use in the organizational context, while utaut2 is a model for improving the predictability of technology and service acceptance and use in a consumer-use context. through empirical analysis, venkatesh et al. (2012) found that utaut2 was a better predictor than utaut of acceptance intention, increasing the explained variance from 56 to 74%, and of technology use from 40 to 52%. however, it is also necessary to identify use intentions by including the perception, attitudes, and expected values of consumers regarding their acceptance of new technologies. based on the utaut model in healthcare system, cimperman et al. (2016) found that health improvement expectancy, facilitation conditions, effort expectancy, and perceived security directly impact use intentions. however, in a study that analyzed the influence of home-based remote healthcare services for the elderly on service use intention, computer anxiety had a negative influence on effort expectancy. wilson and lankton (2004) used tam to explore info-seeking and internet dependence as factors that influence use intentions for healthcare-related it technologies. in a study of factors affecting the acceptance of smart glasses, rauschnabel et al. (2015) underscored the importance of the functional benefits and social compliance and suggested that people with open and outgoing nature trend to be willing to embrace smart glasses. the features, compatibility, aesthetics, and brand of wearable devices were found to impact perceived benefits and value, and they were found to positively impact the use intention (yang et al. 2016 ). many theories have been developed to describe or predict health-related behavior based on the perception that health is affected by social and behavioral factors. the leading models include the health belief model (hbm) and the knowledge, attitudes, and practices (kap) model (humphis 2000) . hbm, was proposed by rosenstock (1974) and becker et al. (1977) expanded and further developed it. hbm was originally developed to improve health education programs for general public (rosenstock, 1974) . however, it has become one of the most widely used social cognition models in health psychology (rosenstock 1974; becker 1977; abraham and sheeran 2015) . the hbm suggested by becker et al. (1977) posits that motivations to initiate and maintain health-protecting behavior are influenced by perception variables, such as personal susceptibility to disease, seriousness, and worries regarding the disease, benefits of taking action, and barriers to behavioral changes (harris and garcia-godoy 2004) . the kap model is based on hbm, which is the most widely used method for prevention activities designed for the general public. the kap model is used to evaluate the knowledge, attitudes, and practices of the general public regarding their health behavior, diseases, and health issues using a structured survey (humphis 2000) . knowledge is a more profound concept than simply understanding, and it includes the acquisition, management, and use of knowledge and technology. attitude is an acquired factor that includes cognitive, emotional, sensory, and behavioral tendencies (raina 2013; rav-marathe et al. 2016) . practice is defined as applying knowledge and rules to result in a final action (badran 1995) . the kap model can be effectively applied to analyze knowledge gaps, cultural beliefs, and behavior patterns among populations, and it facilitates the understanding of individual experiences, opinions, and behaviors (johnston and warkentin 2010; working group on monitoring and evaluation 2014). however, due to the criticism that the kap model ignored the role of beliefs in individual actions, the kapb model was proposed. the kapb model incorporates beliefs into kap. kapb embodies the perspective that understanding one's own health behavior requires comprehending one's life patterns, and action is supported by acquiring basic health knowledge. kapb, which began as a theory of learning, is now widely applied to the field of healthcare and emphasizes the importance of appropriate health information as well as positive beliefs and attitudes for good health practices (frank 2004; johnston and warkentin 2010 ). the kapb model emphasizes the role of practice for improvement, as effort is required to understand the issues with one's current health behaviors before improving them. therefore, the kapb model is often used in health-related fields to provide education for the maintenance and betterment of health, improve attitudes and beliefs, and motivate the intention to act. however, the relationship between consumer behavior and attitudes has yet to be studied using the kapb model, which complements hbm and kap models. the concept of self-efficacy is required to describe the relationship between consumer behavior and attitudes. self-efficacy refers to the individual's confidence in the ability to perform certain actions (bandura 1997) . the potential for action increases with higher self-efficacy and with positive outcome-expectancy. therefore, it is necessary to examine the relationship between the attitudes and actions of consumers. theory of planned behavior (tpb) is a widely known theory that explains the relationship between consumers' attitudes and behaviors. tpb is a concept that expands on the previous tra without its limitations (ajzen 1998; fishbein and ajzen 2010) . tra posits that attitudes towards behaviors and subjective norms influence behavioral intentions, which then lead to behaviors. however, in reality it is necessary for an individual to be in a certain situation (opportunity) to engage in a behavior (taylor et al. 2007) . tpb was developed to predict behaviors in which individuals have incomplete voluntary control. concerning self-esteem and self-efficacy, tpb expands on the concept of perceived behavioral control (ajzen 2002) . tpb, similarly to tam, includes the intention of action; intention refers to the level to which executing specific actions are voluntary and the amount of voluntary effort toward such action (ajzen 1998) . for the purposes of this study, it is important to note that there is a large volume of research that indicates that both tra and tpb have utility in predicting health behaviors and that the observed statistical relationships among their internal constructs, which are based on behavioral, normative, and control beliefs, have significance across a wide range of contexts (armitage and christian 2003) . both models are based on an individual's attitudes and social norms, as well as the person's perceived control as accurate predictors of behavioral intentions, through an evaluation of the available information (ajzen 1998; armitage and christian 2003) . hbm also includes a self-efficacy component to explain health behavior. perception, knowledge, and attitudes toward a health issue may influence health behaviors, as explained by hbm and kapb models. furthermore, an individual requires an expected value from the behavior and self-efficacy to engage in certain behaviors (bandura 1997) . therefore, to understand consumers' use intentions for digital devices, there are multiple aspects of health, attitudes, knowledge, and practices that are directly connected to actual behavior. thus, this study was based on multiple theories discussed in this section as follows. the utaut2 model was used to explain new technology acceptance; the kapb model was used to understand the behaviors associated with implementing health prevention activities, and tpb was used to understand the relationship between consumer attitudes and behaviors. this study analyzed actual use behaviors and continuous use intentions of healthcare wearable devices from the perspective of disease prevention and health management. use intention was defined as the user's intention to utilize new products and services, measured through variables that determine actual behavior to use (davis 1989) . however, as this study focuses on analyzing whether current users of healthcare wearable devices will continue to use them in the future, use intention is excluded from the variables that predict actual use behavior. the proposed research model is presented in fig. 1 . the internal factors in the research model were from kapb, while external factors and user experience were extracted from tpb and utaut2. the study examined two groups: medical personnel and general public. to lead a healthy life, it is necessary for people to engage in health-related behaviors and practices that are habitual activities instead of occasional events. the emergence of various digital devices provides an opportunity to develop healthy life habits. with the increasing diversity in and access to methods of health management, many people are placing importance on user-centric health prevention activities. for health management, related knowledge is a prerequisite to developing good intentions. in general, for health management, it is necessary to obtain accurate health-related information rather than the health management activity itself (dutta-bergman 2004) . for example, such knowledge allows one to search for appropriate health apps that suit the person's objectives and ways to practice them without difficulty. one's drive to lead a healthy life can also influence the person's attitude. for example, an individual pursuing a healthy lifestyle would not smoke as it can cause all sorts of health problems. in other words, if one is trying to achieve an objective, the actual behavior (action) to take would require changes in the person's attitude. believing that the use of health apps or devices would contribute to one's health can positively change his/her attitude. according to tam, the extent to which the user believes that a system is easy to use and useful has a positive effect on use attitude and behavior toward the system (lee et al. 2010 ). braithwaite (2018) argued that knowledge and attitudes gained by individuals in healthcare settings increased their willingness to try new activities. likewise, chen and lin (2018) articulated that individuals with early-adopter characteristics tend to have the positive use intention of new healthcare applications. when a person perceives that the use of new technologies is easy and helpful, his/her internal factors would lead to proactive and positive attitudes that lead to the use intention of healthrelated devices and apps. generally, people with a positive orientation toward a healthy lifestyle tend to search for health-related information and are more likely to learn and apply related technologies and devices (longo et al. 2010; noh et al. 2013; cho 2016) . thus, the following hypotheses are proposed. h1: knowledge, as part of the internal factors that lead to using a healthcare wearable device/application, affects actual use behavior. h2: attitudes, as part of the internal factors that lead to using a healthcare wearable device/application, affect actual use behaviors. h3: beliefs, as part of the internal factors that lead to using a healthcare wearable device/application, affect actual use behaviors. healthcare wearable devices that provide real-time health information and monitoring are recognized as a valuable support tool for an individual's health. healthcare wearable devices can have a significant influence on health-conscious people because they collect, store, and transmit various pieces of information related to health and fitness. if individuals perceive that the services or functions of an application or device are valuable, then they would be positively influenced on the use intention. therefore, when a healthcare application/device is perceived as a useful technical tool, the person's use intention would lead to actual behavior. with the advent of advanced technologies and social change, people are more sensitive to technological changes and consequently tend to be positively inclined to use them (chen and lin 2018) . the importance of social influence was also present as a construct in utaut. venkatesh et al. (2003) proposed that social influence has a positive impact on the use intention of new technologies and devices. in other words, an individual's social characteristics are influenced by others and lead the person to seek social universality. for example, if an influencer recommends the use of healthcare wearable devices, people universally would accept and use such devices. the technological characteristics of healthcare wearable devices and their impact on society would influence people to become future users of the devices. the technological factors (e.g., functions, ease of use, and comfortable) of a healthcare wearable device, as well as the individual and social characteristics (e.g., influence, usefulness, and importance) of the user, can have an influence on the actual behavior of the user. therefore, the following hypotheses are suggested. h4: technological factors, as part of the external factors that lead to using a healthcare wearable device or application, affect actual use behavior. h5: social factors, as part of the external factors that lead to using a healthcare wearable device or application, affect actual use behavior. people with high self-efficacy can develop positive expectations regarding the use of healthcare wearables or applications. typically, individuals expect effective health management with the support of healthcare applications. health improvement expectancy refers to the degree to which users believe that the application of a new technology will result in positive health improvement (venkatesh et al. 2003; bozan et al. 2015) . therefore, health improvement expectancy can be a predictor of continuous use intention (venkatesh et al. 2003; bozan et al. 2015) . in general, users who perceive the effectiveness of a certain behavior tend to repeat it and achieve the intended objective through its repetition (lee et al. 2010 ). thus, users who focus on the objective of health management by using healthcare wearables and applications will strive to achieve their health improvement expectancy goals, such as disease prevention and health management. if the results exceed expectations, individuals will tend to encourage others to try them. therefore, users expect to achieve their health improvement expectancy goal by using healthcare wearables and applications (lee 2018 ). if a colleague or friend recommended a healthcare wearable device, the individual would develop high expectations about the device. the individual would be satisfied with the device if it provided or exceeded the expected health improvement but would become dissatisfied if the results were disappointing. therefore, behavior for actual use influences health improvement expectancy. furthermore, disease prevention and health information have typically been used for the supplier-centric medical services of healthcare providers. however, the emergence of a diverse range of healthcare devices and applications has helped shift this trend to user-centric healthcare services, leading many consumers to use wearable devices for health improvement expectancy (lee 2018) . hence, the following hypothesis is proposed. h6: the actual use behavior of healthcare wearable devices/applications has a positive effect on health improvement expectancy. the continuous use intention refers to the willingness of the user to continue using specific products and services in the future (bhattacherjee 2001) . in a study conducted to identify factors that affect the use intention of home-based remote health services for the elderly, cimperman et al. (2016) found that the health improvement expectancy directly influences service use intentions of home-based remote health services. a high level of belief in the use of healthcare wearable devices triggers the expected value of the devices for health management, which will lead to use intention. in addition, when users believe that the application of healthcare wearable devices is convenient for monitoring and preventing health issues, they will be willing to continue using them. in other words, believing that usage of a healthcare wearable device would lead to improving one's expected health could lead to the intention to use the said technology or device. the continuous use intention can be an important contributor to health improvement expectancy as it is a result of customer satisfaction. as customer satisfaction is enhanced when customers' expectations are met, health improvement expectancy will influence continuous use intention. the following hypothesis is developed. h7: health improvement expectancy associated with the use of healthcare wearable devices/applications has a positive effect on continuous use intention. to test the proposed research model with associated hypotheses, we collected data from medical personnel and general public through a survey questionnaire. as most of the measurement items in the questionnaire were from previous studies, we undertook the double translation protocol (harkness 2011) . the questionnaire was first developed in english and then was translated into korean by a bilingual faculty member in the service operations management area. the korean version of the questionnaire was then translated back into english by another bilingual faculty in the healthcare management field. three bilingual faculty examined the two english versions and found no significant difference. the questionnaire was tested in a pilot survey involving thirty-five participating volunteers (15 medical personnel and 20 general public). after the pilot study, several measurement items of the constructs were modified because the survey participants found them ambiguous and difficult to answer. we distributed 500 questionnaires of the final version to each group: medical personnel and general public. for the medical personnel group, we randomly selected doctors, nurses, medical technicians, and pharmacists at several general hospitals that accepted our request for data collection, as well as staff at public health centers. for the general public group, we also randomly selected volunteers among businesspeople, visitors to health centers or hospitals, university employees, and college students. we factored in respondents' behavior to minimize respondent variance in each group. subsequently, a total 288 useable questionnaires were received (a response rate of 28.8 for the sample group); medical personnel-129 out of 500 questionnaires distributed (a response rate of 25.8%); general public-159 of 500 distributed (a response rate of 31.8%). the final questionnaire is shown in table 1 and provides measurement items for knowledge, attitude, belief, technological and social factors, actual use behavior, health improvement expectancy, and continuous use intention. the characteristics of respondents are summarized in table 2 . the categorized respondent types are medical personnel (44.79%) who are engaged in the healthcare field and general public (55.21%) representing non-healthcare related persons. in the sample, 100% of the respondents had experience using healthcare wearable devices/apps, 87.85% for more than one year. the three types of healthcare wearable devices/apps the respondents have used are smartwatch davis et al. (1989) ; venkatesh et al. (2003) ; cimperman et al. (2016) hi2: using product a helped manage health hi3: using product a has helped make life convenient hi4: using product a helped me lead a regular lifestyle continuous use intention level of willingness to continue using or recommend product a co1: i will continue to use product a venkatesh et al. (2003) ; cho (2016) co2: i will continue to use product a frequently co3: i am willing to use product a in the future co4: i will recommend people around me to use product a (52.78%), fitbit (28.47%), and smartphone with health apps (18.75%). the main purpose of using healthcare wearable devices/apps was listed in the following order: activity measure (37.15%), heart rate (23.96%), stress index (23.96%), sleeping (11.81%), and blood pressure (3.13%). to overcome an uncertain crisis like covid-19, respondents thought healthcare devices/apps can help strengthen the following: immune system (43.75 %), exercise (32.64 %), relieve stress (14.93%), and walk (8.68 %). the questionnaire utilized 5-point likert scales to measure the constructs. measurement items from previous studies were modified to fit this research. this study employed spss 23.0 and amos 23.0 programs. structural equation modeling (sem) was chosen because it provides the tools necessary to test the hypotheses. reliability is estimated using cronbach's alpha values (table 3 ). all the coefficients for the constructs exceeded the threshold value of .70 for exploratory constructs (nunnally 1978) . in the reliability test, cronbach's alpha for social factors was the highest (.839) and knowledge was the lowest (.727). all the cronbach's alpha values were significant at p < .05. table 4 presents the fit indices of cfa for the whole sample, group1, and group2. based on the recommended threshold values, cfi, rmr srmr, rmsea, and χ 2 /df were satisfactory for the whole sample model, but not gfi. group1 and group2 satisfied all the recommended values. as validity refers to the accuracy of measurement items, confirmatory factor analysis (cfa) is a way of testing how well measured variables represent the constructs for the study. table 3 shows the standardized factor loadings and t-values for measurement variables and results of cfa to test measurement models for the whole sample, group1 (medical personnel), and group2 (general public), using the amos program. the values of standardized regression weights for knowledge, attitude, belief, technological factors, social factors, actual use behaviors, health improvement expectancy, and continuous use intention were all greater than .5, indicating all variables proposed by the study were statistically significant at the .05 level. the convergent validity, which requires the average variance extracted (ave), should be greater than .5 (fornell and larcher 1981) . all measurement items met the threshold value as shown in table 5 . since the values of composite reliability (cr) of knowledge, attitude, belief, technological factors, social factors, actual use behaviors, health improvement expectancy, and continuous use intention were all greater than .7, convergent validity was satisfied. the off-diagonal elements are the correlation between latent variables in table 5 . for adequate discriminant validity, the square root of the ave of any latent variable should be greater than the correlation between a given latent variable and other latent variables (barclay et al. 1995) . as shown in table 5 , statistics satisfied this requirement, lending evidence of discriminant validity. after examining the measurement model using partial least squares, the relations between the constructs were addressed. the hypotheses were tested by exploring the path coefficients. as a result of the goodness of fit test, compared to the recommended values, in this model, the values of cfi (.918), rmsea (.053), rmr (.067), srmr (.072), and χ 2 /df (2.289) were good fit indices, but gfi (.830) was below the required threshold. table 6 presents the result of the significance test for the research model with hypotheses. for h1, h2, and h3, the standardized path coefficient between actual use behaviors and knowledge (h1), attitudes (h2), and beliefs (h3) were .436, .177, and .174, respectively. these three hypotheses were statistically significant at the .01 level and thus supported. the results of this study are similar to that of previous studies of the users with high internal knowledge, attitudes, and beliefs about the use of healthcare wearable devices/apps that more likely would lead to their actual use (e.g., cho 2016; chen and lin 2018) . this means that the actual use of the healthcare wearable devices/apps is based on the users' knowledge about healthcare, changing attitudes toward healthcare, and belief in using devices. for h4 and h5, the standardized path coefficients between actual use behavior and technological factors (h4) and social factors (h5) were .155 and .153, respectively, and statistically significant at the .05 level, supporting both hypotheses. these results are also similar to those of previous studies (e.g., venkatesh et al. 2003; chen and lin 2018) . for example, if users can easily access certain technology systems, then lead to actual use behavior. the new healthcare wearable devices/ apps can invoke actual use behavior to create value through easy access to technology systems. for h6, the standardized path coefficient between actual use behavior and health improvement expectancy was .976, and statistically significant at the .001 level, supporting the hypothesis. for h7, the standardized path coefficient between health improvement expectancy and continuous use intention was .337, and statistically significant at the .001 level, also supporting h7. these results are similar to that shown by previous studies, the higher the expected performance for health improvement through the device the higher the intention to use continuously (e.g., venkatesh et al. 2003; bonzan et al. 2015; cimperman et al. 2016) . if inpatients had a positive health improvement experience with healthcare wearable devices/apps, they tend to share their experiences and recommend others to use devices/apps. it means that direct or indirect experiences or expected values impact on continuous use intention of wearable devices/apps. this study collected data from two groups: medical personnel and general public. medical personnel refer to a group of people who are always exposed to disease treatment/prevention and health promotion situations, while general public refers to a group that is not. structural equation modeling (sem) with amos 23 was employed to conduct a comparative analysis of the two groups to discover whether different conditions may moderate the relationships among the constructs under study. to examine the model comparing the two groups, the study employed covariance matrices to perform a measurement equivalence test via confirmatory factor analysis (cfa) in amos version 23. this allowed us to examine various combinations of constrained and unconstrained models to determine "the source of any differences in the way the constructs are composed and interpreted in the different cultures" (myers et al. 2000) . the results of the cfa model comparing the two groups are shown in table 7 . first, model 1 produced a χ 2 of 1450.690 (df = 764), a cfi of .930, and an rmsea of .056. the second model (model 2) was executed to determine whether the measurement model is equivalent to the two groups. the χ 2 difference between models 1 and 2 was non-significant (δχ 2 = 1.289). this suggests that the measurement scale is assumed to be equivalent across the two groups (myers et al. 2000) . model 3, constrained for factor correlations (φ) and factor loadings (λ), was not significantly different from model 2 (δχ 2 = 1.092, df = 2; cfi = .929; rmsea = .055). this finding implies that factor correlations and factor loadings are constrained such that they are equal (myers et al. 2000) . model 4 estimated the error variances (θ) to be equal across the two groups. model 4 was significantly different from model 1 (δχ 2 = 13.34; df = 17; cfi = .906; rmsea = .055). based on table 7 , we are assured that the measurement items for each construct have high convergent and construct validity to test the research model for each group. the results of the comparative analysis for the two groups with path coefficients (medical personnel and general public) are shown in table 8 . all path loadings were significant at the .05 level. the effect of health improvement expectancy on continuous use intention was supported for both groups (h7: β =.336 and β = .346, respectively). the following hypotheses were supported for both groups: the effect of knowledge on actual use behavior (h1: β = .425 and β = .456, respectively); the effect of attitudes on actual use behavior (h2: β = .249 and β = .337, respectively); the effect of beliefs on actual use behavior (h3: β = .315 and β = .163, respectively); the effect of technological factors on actual use behavior (h4: β = .314 and β = .172, respectively); the effect of social factors on actual use behavior (h5: β = .247 and β = .252, respectively): and the effect of actual use behavior on health improvement expectancy (h6: β = .696 and β = .476, respectively). as shown in table 8 , overall, .003* the medical personnel group showed a higher degree of relationships between factors on unstandardized coefficient. the coefficients and significant values were different between the two groups as well. this study combined kabp, tpb, and utaut2 models for an empirical analysis of factors that influencing the continuous use intention of healthcare wearable devices or applications. furthermore, the study performed a comparative analysis of the two groups in the sample: medical personnel and general public. a research model, along with associated hypotheses, was proposed. the results of the study revealed that continuous use intention of healthcare wearable devices/apps should be prioritized for improving health conditions or preventing diseases. the study results confirmed the positive effects of knowledge (h1), attitudes (h2), and beliefs (h3) of internal factors on actual use behavior of healthcare wearables/apps. these results shed new insights about how healthcare wearable device manufacturers can develop their products to increase user intention to use them. the actual use behavior is influenced by internal factors. the study also found positive relationships between actual use behavior and technological factors (h4) and social factors (h5), as part of external factors. since the actual use behavior is influenced by social trends and convenience of using technology, it is important to provide a good user experience. these results indicate that both internal and external factors are important for increasing actual use behavior, based on the social and technical demands of customers. in addition, the results of the study revealed positive relationships between actual use behavior and health improvement expectancy (h7). humphis (2000) suggested that "improved population health depends on changing the behavior of people," such as who are healthy (e.g., people with regular exercise regime), who are ill (e.g., heavy smokers), and how health promotion is delivered (e.g., community health clubs). the study results confirmed that all proposed hypotheses were supported for both groups (medical personnel and general public: h1, h2, h3, h4, h5, h6, and h7). however, overall, the medical personnel group showed higher levels of significance in the relationships than the general public group. since medical staffs are always concerned with healthcare, they are highly willing to use wearables/apps with high expectations for improved health management. with the current covid-19 pandemic crisis around the globe, the interest in healthcare wearables/apps has increased tremendously (phaneuf 2020) . especially, there is a strong new trend for "untact" healthcare services, such as e-healthcare or tele-healthcare . considering these uncertainties, it is reasonable to assume that the demand for healthcare wearables/apps will continue to increase in the future phaneuf 2020) . the values of explanatory power (r 2 ) of the five antecedent variables on actual use behaviors are as follows: knowledge: .127 (f = 41.554), attitudes: .176 (f = 61.268), beliefs: .163 (f = 55.523), technological factors: .164 (f = 56.310), and social factors: .277 (f = 109.626). although the explanatory power values (0 <r 2 < 1) appear to be low, they were significant at p < .000. the results indicated that social factors variable was most significant among five antecedent variables for actual use behaviors and continuous use intention of healthcare wearables/apps. the greatest significance shown by social factors imply that most people are influenced by their social surroundings for using or continuous use intention of healthcare wearables. the results of the study have significant practical implications for the healthcare industry. the healthcare environment has witnessed a shift from treatment-centered services to prevention and management-centered services with the patient's selfcontrol and use of advanced healthcare devices (lee 2018; lee and lee 2020) . in addition, public interest in health has grown significantly with the aging population, which has given rise to demands for customized healthcare services with self-management or heath control devices. today, there is a diverse type of smart healthcare wearable devices, tools, or apps available and new ones are being introduced to the market (e.g., alivecor's personal ekg, temptraq to monitoring the temperature, blinq wearable rings, philips smart sleep, wireless patient monitoring, etc.). health-related institutions and policymakers should make it easy and simple to use wearable devices. manufacturers of wearable devices should lower the price of their products so that general public can purchase and use them for their health benefits. lindhult et al. (2018) suggested that product-oriented manufacturing companies need to understand consumer needs and pursue service innovation to create greater value for consumers. therefore, the results of this study can provide practical guidelines for the producers of healthcare wearables/apps that may provide value for the greater good. the results of this study can also be useful for developing new remote healthcare services through mobile devices. while this study yielded interesting results, it also has several limitations. the study is based on the data collected from the users of user-centric healthcare wearable devices and applications; however, it did not analyze the specific characteristics of these devices and applications. therefore, it is necessary to apply the results of this study after identifying the functions and services expected by the users. this study did not comprehensively examine the influence of individual user's characteristics, health status, and the sustainable use intention of wearables or apps. these limitations provide future research opportunities. it is also important to consider how new or additional health data can be generated and used by wearables and apps. this is a sensitive area that involves data security, privacy, and the digitalization of healthcare data. there are many new future research opportunities in this area, such as contact tracing for the covid-19 infected patients using such wearable devices. predicting and changing health behavior: research and practice with social cognition models, 3 rd patient adoption of mhealth: use, evidence and remaining barriers to mainstream acceptance perceived behavioral control, self-efficacy, locus of control, and the theory of planned behavior models of human social behavior and their application to health psychology technology acceptance models and adoption of innovations: a literature review from attitudes to behavior: basic and applied research on the theory of planned behavior knowledge, attitude and practice the three pillars of excellence and wisdom: a place in the medical profession self-efficacy: the exercise of control the partial least squares (pls) approach to causal modeling: personal computer adoption and use as an illustration the health belief model in the prediction of dietary compliance: a field experiment understanding information systems continuance: an expectation-confirmation model social influence on health it adoption patterns of the elderly: an institutional theory-based use behavior approach changing how we think about healthcare improvement reimagining medtech for a covid-19 world. mckinsey & company incorporation of health consciousness into the technology readiness and acceptance model to predict app download and usage intentions the impact of post-adoption beliefs on the continued use of health apps analyzing older users' home telehealth services acceptance behavior-applying an extended utaut model covid-19 and commercial pharma: navigating an uneven recovery perceived usefulness, perceived ease of use, and user acceptance of information technology extrinsic and intrinsic motivation to use computers in the workplace primary sources of health information: comparisons in the domain of health attitudes, health cognitions, and health behaviors development of mhealth applications for pre-eclampsia triage predicting and changing behavior: the reasoned action approach evaluating structural equation models with unobservable variables and measurement error mobile health technology adoption across generations: narrowing the digital divide physician health and patient care technology acceptance in health care: an integrative review of predictive factors and intervention programs guidelines for best practice in cross-cultural surveys primary preventive dentistry. 6 th behavioral sciences for dentistry fear appeals and information security behaviors: an empirical study a study on the knowledge, opinions and practices about oral health of workers in korea strategies for technology-driven service encounters for patient experience satisfaction in hospitals a model for designing healthcare service based on the patient experience the effect of organizational support on erp implementation untact": a new customer service strategy in the digital age value logics for service innovation: practice-driven implications for service-dominant logic health information seeking, receipt, and use in diabetes self-management mhealth solutions market worth 90.49 billion usd by 2022 an application of multiple-group causal models in assessing cross-cultural measurement equivalence a test of extended technology acceptance model on health information seeking on the internet a context aware wireless body area network (ban). pervasive computing technologies for healthcare wearable lab on body: combining sensing of biochemical and digital markers in a wearable device a review of wearable sensors and systems with application in rehabilitation latest trends in medical monitoring devices and wearable health technology assessment of knowledge, attitude, and practice in health care delivery who will buy smart glasses? empirical results of two pre-market-entry studies on the role of personality in individual awareness and intended adoption of google glass wearables the role of connected wearable devices in healthcare. iot for all a systematic review on the kap-o framework for diabetes education and research historical origins of the health belief model keynote speech at hearing loss association of america conference a review of the use of the health belief model (hbm), the theory of reasoned action (tra), the theory of planned behaviour (tpb) and the trans-theoretical model (ttm) to study and predict health related behaviour change understanding information technology usage: a test of competing models a theoretical extension of the technology acceptance model: four longitudinal field studies user acceptance of information technology: toward a unified view consumer acceptance and use of information technology: extending the unified theory of acceptance and use of technology investigating the determinants and age and gender differences in the acceptance of mobile learning modeling patients' acceptance of provider-delivered e-health knowledge, attitudes, and practices (kap) surveys during cholera vaccination campaigns: guidance for oral cholera vaccine stockpile campaigns user acceptance of wearable devices: an extended perspective of perceived value innovative healthcare wearable device usage and service enhancement publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-321098-j3glby40 authors: bodrud-doza, md.; shammi, mashura; bahlman, laura; islam, abu reza md. towfiqul; rahman, md. mostafizur title: psychosocial and socio-economic crisis in bangladesh due to covid-19 pandemic: a perception-based assessment date: 2020-06-26 journal: front public health doi: 10.3389/fpubh.2020.00341 sha: doc_id: 321098 cord_uid: j3glby40 background: the spread of the covid-19 pandemic, the partial lockdown, the disease intensity, weak governance in the healthcare system, insufficient medical facilities, unawareness, and the sharing of misinformation in the mass media has led to people experiencing fear and anxiety. the present study intended to conduct a perception-based analysis to get an idea of people's psychosocial and socio-economic crisis, and the possible environmental crisis, amidst the covid-19 pandemic in bangladesh. methods: a perception-based questionnaire was put online for bangladeshi citizens of 18 years and/or older. the sample size was 1,066 respondents. datasets were analyzed through a set of statistical techniques including principal component and hierarchical cluster analysis. results: there was a positive significant association between fear of the covid-19 outbreak with the struggling healthcare system (p < 0.05) of the country. also, there was a negative association between the fragile health system of bangladesh and the government's ability to deal with the pandemic (p < 0.05), revealing the poor governance in the healthcare system. a positive association of shutdown and social distancing with the fear of losing one's own or a family members' life, influenced by a lack of healthcare treatment (p < 0.05), reveals that, due to the decision of shutting down normal activities, people may be experiencing mental and economic stress. however, a positive association of the socio-economic impact of the shutdown with poor people's suffering, the price hike of basic essentials, the hindering of formal education (p < 0.05), and the possibility of a severe socio-economic and health crisis will be aggravated. moreover, there is a possibility of a climate change-induced disaster and infectious diseases like dengue during/after the covid-19 situation, which will create severe food insecurity (p < 0.01) and a further healthcare crisis. conclusions: the partial lockdown in bangladesh due to the covid-19 pandemic increased community transmission and worsened the healthcare crisis, economic burden, and loss of gdp despite the resuming of industrial operations. in society, it has created psychosocial and socio-economic insecurity among people due to the loss of lives and livelihoods. the government should take proper inclusive steps for risk assessment, communications, and financial stimulus toward the public to alleviate their fear and anxiety, and to take proper action to boost mental health and well-being. the novel coronavirus disease (covid-19) began spreading in november 2019, in wuhan, china. following this, the world health organization (who) announced covid-19 as a global pandemic on march 11th, 2020 (1) . covid-19 has advanced into a pandemic, starting initially as small clusters of transmission that combined into larger clusters in many countries, subsequently resulting in a widespread transmission (2) . social isolation, institutional and home quarantine, social distancing, and community containment measures were applied without delay (3) . through quick administrative action and raising awareness for individuals on social-distancing, stringent steps were taken to manage the spread of the disease by canceling thousands of locations that involved social gathering including offices, classrooms, reception centers, clubs, transport services, and travel restrictions, leaving many countries in complete lockdown (4) . the remarkable actions and ventures in public health to quarantine mass numbers has prevented this virus from spreading exponentially between humans in china, singapore, hong kong, and south korea, despite initial cases (2, 5) . however, a surge of covid-19 outbreaks in all inhabitable continents, with 84,187 deaths alone in the usa, indicates that the infection had passed the tipping point (1, 6) . today, as of the 26th of may 2020, total global covid-19 cases have risen to 5,637,381, with the total number of deaths escalating to 3,49,291 (7) . the accelerating spread of covid-19 and its outcomes around the world has led people to experiencing fear, panic, concern, anxiety, stigma, depression, racism, and xenophobia (8) . bangladesh confirmed their first covid-19 case on the 8th of march 2020 (9), followed by a nationwide lockdown from 26 march which had been extended several times until 30th may 2020 to prevent human transmission. the government deployed armed forces to facilitate social distancing on march 24th. emergency healthcare services and law enforcement were exempt from this announcement. yet more than 11 million people left dhaka to return to their home districts and thus helped spread the diseases nationwide. moreover, from the 25th of april 2020, all ready-made-garment (rmg) factories, industries, private offices, and business centers were allowed to open, leading to a "partial lockdown" in the country. the migration of rmg workers to the industrial districts and less community awareness about the disease has increased the transmission among millions of people. the institute of epidemiology disease control and research (iedcr), under the ministry of health and family welfare (mfhw) and directorate general of health services (dghs), is responsible for researching epidemiological and communicable diseases such as covid-19 in bangladesh, as well as disease control and surveillance. initially, iedcr was the single and centralized laboratory for covid-19 testing in bangladesh (9) . the dghs, on the other hand, is the responsible body for the coordination of testing and sample collections of covid-19 patients (10) . as of the 26th of may 2020, according to iedcr, the total number of covid-19 positive cases stands at 36,751 with 522 deaths (figures 1a,b) . according to iedcr, those aged between 21 and 40 are with the highest number of cases (55%), while those aged above 60 have had fatal cases of the disease (42%). at present, the fatality rate in bangladesh is 1.41% (26th may 2020) which was initially 10.4% (8th april 2020) (9) . although the number of laboratories for covid-19 testing has increased to 48, all these labs are in major urban areas of bangladesh and to get tested requires long waiting hours. more often the tests have been done after the patients had died. very recently, more than 15% of those tested daily have tested as positive (figure 1c) , and the ratio of testing is 1,620/1 million people. in addition, it also takes a long time to get the result of the tests. furthermore, there are only 1,169 intensive care unit (icu) beds in the country, of which 432 beds are in government hospitals and 737 in private hospitals. it is predicted that as the number of patients rise, the required number of icu facilities will not be adequate (9) . in addition, the healthcare staff and doctors were given low quality/no personal protective equipment (ppe) which has caused a high infection rate among them (11) . moreover, as laboratory staff, healthcare staff, and doctors have become increasingly infected, there is also a shortage of specialized trained personal to perform covid-19 tests, meaning patient treatment will be disrupted. amidst the lockdown, due to the fear of contact transmission, private hospitals and clinics are not providing any services (11) . the shortage of healthcare facilities for primary and critical care patients have therefore been depleted. the healthcare workers who have treated patients and become infected have been criticized socially and have faced social stigma from local people. in many locations public protests were observed against the establishment of quarantine facilities, covid-19 care hospitals, and clinics. social humiliation was a common practice of law enforcement authorities and government officials. on many occasions, family members left the infected and the deceased in the hospitals. the deceased were even denied burials in local graveyards, which are basic cultural rights as a muslim (12) . moreover, the lockdown hit hard for those who earn daily wages and low and middle-income people who lost their jobs and their income source. the anxiety and fear of death from hunger or death from infection led to several suicide cases (13) . predictably, any contagious epidemic outbreak has harmful effects on individuals and society (14) . considering the population density, educational status, social structure, cultural norms, healthcare capacity, and often flawed policies taken by the government of bangladesh, it is hard to lock down a country of 165 million people. moreover, bangladesh hosts the largest refugee camps in the world in the cox's bazar district. the rohingya refugees who fled from myanmar reside in the camps of cox's bazar. 21 confirmed cases were found in the camps while the district had reported 435 confirmed cases (9) . this depicts the scenario of public anxiety which should be immediately dealt with by the government, along with the alliance groups, with proper information. amidst the current societal levels of anxiety and fear, the possibility of natural disasters such as tropical cyclones and monsoon floods and the potential for a dengue outbreak, seasonal influenza, or other infections are potentially overlooked. furthermore, the consequences of incorrect disposal of used personal protective equipment (ppe) from covid-19 hospitals without proper treatment in landfill sites has the potential for further disease transmission among the waste management personal and further environmental transmission. considering the given circumstance, this study was designed to analyze the psychosocial, socio-economic, and possible environmental crisis based on public perception in bangladesh due to the covid-19 outbreak. this assessment may inform the government and policymakers of countries with a similar socioeconomic and cultural structure to bangladesh. to understand the possible psychosocial, socio-economic, and environmental impact of the covid-19 outbreak in bangladesh, we considered and identified several relevant and possible items based on the socio-economic situation, political analysis, the existing healthcare system, environmental analysis, possible emerging issues utilized from scenario developments, analysis of local and global reports of the covid-19 pandemic from the print and electronic media, and a literature review. we prepared the questionnaire considering the demographic characteristics of bangladesh, societal mental health conditions (mh), the healthcare system in bangladesh (hsb), governance and political issues (gpi), socio-economic issues (sei), immediate emerging issues (iei) and enduring emerging issues (eei). a total of 46 items were considered in the drafted questionnaires to understand people's perception of the covid-19 outbreak in bangladesh. furthermore, expert consultation was considered to set and validate these 46 items. we prepared the online-based questionnaire through google to operate the survey nationwide. an introductory paragraph describing the objective of the questionnaire was shared with the respondents through email and through social platforms commonly used by bangladeshi groups on facebook, messenger, linkedin, and whatsapp. relevant people were selected for targeted sampling. an online database of target participants was prepared by reviewing relevant websites and online social platforms of different groups in bangladesh. the sample group was targeted considering bangladeshi citizenship, their age, current activities, occupation, social and economic responsibilities, and engagement related to covid-19 response, planning, and policymaking. the questionnaire survey was conducted from 28 march to 30 march 2020 during the lockdown period. the respondents belonged to different social categories, such as university faculty members and scholars, government officials, development workers or practitioners, doctors, engineers and technologists, youth leaders and students, businessmen and industry officials, banking and finance corporates, and independent researchers, among others. the answers to the survey questionnaire were voluntary. data from 1082 respondents were collected through this online survey initially using the simple random sampling method following keeble et al. (15) . following the removal of 16 incomplete questionnaires, 1,066 responses were finally retained for this study. a five-point (1 to 5) likert scale was used for testing the statement descriptions that ranged from strongly disagree to strongly agree with the statements ( table 1) . there was a limitation of the rapid assessment on the publicperception on the psychosocial and socio-economic crisis in bangladesh due to the covid-19 pandemic. as the study was conducted during the lockdown period, it was not possible to reach to general people physically. therefore, we had to keep our samples limited to internet users only. there are more than 95 million mobile internet users in bangladesh and, as a youthdividend country, the majority of the mobile internet users are young educated people. the descriptive statistics [e.g., frequencies, percentages, and ttest (data provided in supplementary tables)] were employed to understand respondents' characteristics. an investigation of psychometric characteristics was included in the classical test theory (ctt) analysis. a set of statistical techniques, including linear regression analysis (lra), principal component analysis (pca), and hierarchical cluster analysis (ca), were applied to explore the association between the items. pca is a data reduction tool that demonstrates each potentiality of parameters and their confidence level in large sample datasets. before conducting the pca, kaiser-maier-olkin (kmo) and bartlett's sphericity tests were applied to confirm the necessity of this analysis. the results of the kmo at >0.5 (the kmo value was 0.931 in this work) and the significance of bartlett's sphericity test at p < 0.01 supported our datasets to be fitted for the pca (16) . the number of factors chosen was based on the kaiser's principle, where the only factors with eigenvalues>1.0 were considered. cronbach's alpha was employed to test the consistency and reliability of the factor loadings in this study. cronbach's alpha values at >0.06 (the cronbach's alpha value was 0.896) are regarded to be suitable in social science research (17) . the ca is a crucial means of detecting associations among many psychosocial and environmental parameters. ca assists to demarcate a population into various groups based on the same feature of a set of the dataset that may reveal causes, effects, and/or the source of any unidentified relationships among the items. furthermore, hierarchical clustering was used to determine the probable number of clusters. statistical package for the social sciences (spss) v. 25.0 was used for the analysis of the datasets. the consent of the respondents was taken before the survey, and their anonymity was guaranteed. all the participants were informed about the specific objective of this study before proceeding to the questionnaire. participants were able to complete the survey only once and could terminate the survey at any time they desired. anonymity and confidentiality of the data were ensured. formal ethical permission of this study was taken from the respective authority. a total of 1,066 (=n) responses were recorded in this study. the proportion of male to female respondents was 3:2 [males (n = 661; 61.5%) and females (n = 405; 38.5%)]. the composition of age groups of the respondents was as follows: 75.2% (18-30 years old), 16.7% (31-40 years old), 6.7% (41-50 years old), 1.1% (51-60 years old), and 0.3% (>60 years old). the average age of the respondents was 27.80 years (sd ± 10.05). on average, the respondents had 12.5 years of formal education (sd ± 8.1). 60% of the youth group were mostly students or at the brink of finishing their studies. the remaining 40% of the respondents were from various professions, including doctors and healthcare workers, civil service officials, non-government officials (ngos), teachers and scholars, policymakers, researchers, and businessmen. the descriptive statistics containing the 46 statements are shown in table 1 . the category of statements were grouped as follows: mental health condition (mh) comprised five statements (mh1-5), the healthcare system of bangladesh (hsb) comprised ten statements (hsb1-10), the governance and political issues (gpi) comprised 7 statements (gpi1-7), the socio-economic issues comprised 11 statements (sei1-11), the immediate emerging issues comprised 7 statements (iei1-7), and for enduring emerging issues 6 statements were considered (eei1-6). in the following section of mental health status, healthcare system, governance and political perspective, socio-economic aspects, and emerging issues, we have discussed the descriptive statistics. in the statement of "i am afraid of the recent outbreak of coronavirus in bangladesh" (mh1) 46.2% of the respondents strongly agreed, followed with a mean of 4.15 ± 1.01. in the second statement (mh2), "i am afraid of getting infected with coronavirus" the difference among strongly agreed (32.7%) and agreed (33.5%) statement with a mean value of 3.89 ± 1.08. for statement three, 46.5% of the respondents strongly agreed to the (mh3) "i am afraid of losing my life or my relatives' life due to this outbreak" with a mean value of 4.08 ± 1.08. in the fourth 62% of the respondents strongly agreed to the statement that the healthcare system of bangladesh is fragile and unable to deal with the recent outbreak of covid-19 (hsb1), with a mean value of 4.36 ± 1.01. for the second statement, 68% of respondents with a mean value of 4.51 ± 0.87 strongly agreed that "a huge population is a pressure to the existing healthcare system to deal with covid-19" (hsb2). 67% of the respondents with a mean value of 4.55 ± 0.776 strongly agreed that "there is a lack of awareness of basic healthcare issues in most of the citizens of bangladesh" (hsb3). moreover, 52% of the respondents with a mean value of 4.22 ± 1.0 strongly agreed that there is "a lack of trained doctors and healthcare professionals to deal with the covid-19" (hsb4). with a mean value of 4.64 ± 0.73, 75.4% of the respondents strongly agreed that "the lack of healthcare facilities will be unable to combat the covid-19 outbreak in bangladesh" (hsb5). again, 73% of respondent with a mean of 4.6 ± 0.77 strongly agreed with "the lack of healthcare infrastructure to deal with covid-19" (hsb6). for statement seven, 68.5% of respondents with a mean value of 4.56 ± 0.734 strongly agreed that "there is a severe lack of bio-medical and hospital waste management facilities in bangladesh" (hsb7). moreover, 82% of respondents with a mean value of 4.72 ± 0.71 strongly agreed that "there is a lack of covid-19 testing facility in bangladesh" (hsb8). 49.2% of respondents (4.05 ± 1.86) strongly agreed that "the budget is inadequate or there is a lack of financial support to respond to this outbreak" (hsb9). finally, 75.8% of respondents with a mean value of 4.64 ± 0.74 strongly agreed that "most of the poor people will not have access to the existing healthcare facilities if they are infected with covid-19" (hsb10). regarding the statement of "the bangladesh government can deal with this outbreak" (gpi1), the public opinion did not vary significantly with a mean value of 2.50 ± 1.28. similar responses were also found in response to "the government is taking this outbreak seriously" (gpi2) with a mean value of 2.76 ± 1.26 and "the government is taking proper decisions at the right time" (gpi3) with a mean value of 2.27 ± 1.19. 68.6% of respondents strongly agreed that "the government needs support from the general public to reduce the impact of covid-19" (gpi5) with a mean value of 4.56 ± 0.77 and that "the government needs to formulate a policy and action plan and implement it immediately" (gpi6) with a mean value of 4.67 ± 0.69. about 31.6% of respondents agreed that "developed nations are going to support bangladesh in response to covid-19" (gpi7) with a mean value of 3.45 ± 1.0. nearly 61-65% of respondents strongly agreed that "the shut down or lockdown of regular activities was a good decision to reduce the chance of infection of covid-19" (sei1) (mean 4.53 ± 0.77), "this will have an economic and social impact in the future" (sei2) (mean 4.51 ± 0.77), and that "both formal and informal businesses will be hampered" (sei3) (mean 4.5 ± 0.71). for the fourth statement, 85.6% of respondents strongly agreed that "poor people living off daily wages will be severely affected" (sei4) with a mean of 4.78 ± 0.60, while 60.5% strongly agreed that "most of the poor people living in urban areas have to leave the city due to not having any options for income" (sei5) (mean 4.42 ± 0.87). 54.8% (mean 4.36 ± 0.85) of the respondents agreed that "many people will lose their livelihood/ jobs at this time" (sei6). a further 42.9% (mean 4.13 ± 0.97) strongly agreed that "there will be a reduced supply of basic goods/ products for daily use" (sei7) and 50.8% (mean 4.28 ± 0.89) strongly agreed that "there was or will be increased prices for basic products" (sei8). consequently, "poor people will suffer food and nutritional deficiency" (sei9) was strongly agreed with by 69.4% respondents (mean value of 4.6 ± 0.712). "the shutdown of education institutes will hamper those currently receiving formal education" (sei10), to which 57% respondents strongly agreed (mean value of 4.38 ± 0.88). for "if there is a chance of social conflict due to this outbreak" (sei11), the mean response was 3.9 ± 1.06. 56.4% (mean 4.39 ± 0.82) of respondents strongly considered that "there is a chance of community transmission of covid-19 in bangladesh" (iei1) and that "a huge number of people will be infected" (iei2) with a mean value of 4.208 ± 0.93. moreover, 69% of the respondents strongly agreed (mean value 4.56 ± 0.74) that "there is a chance that many infected patients will not be detected due to a lack of testing facilities and this will not show the actual number of infected cases" (iei3). approximately 61-67% of the respondents strongly agreed that "there is a chance of an increasing numbers of deaths from infection due to a lack of proper health facilities" (iei4) with a mean value of 4.56 ± 0.74. "a lack of bio-medical waste management facilities in the hospitals will create further transmission" (iei5) received a mean value of 4.50 ± 0.73. for the sixth statement, 46.4% of respondents (mean value of 4.28 ± 0.88) strongly agreed that "there will be many people psychosocially shocked due to this outbreak" (iei6) and that "the general public will lose trust in the government" (iei7) was strongly agreed with by 36.4% respondents with a mean value of 3.83 ± 1.12. we have considered emerging enduring issues (eei), such as potential natural calamities and infectious disease outbreaks, as the monsoon season is approaching. six statements were considered for enduring emerging issues (eei1-6). regarding the statement that "there is a chance of a disaster such as a flood, cyclone, or drought in 2020 considering the vulnerability of bangladesh to climate change" (eei1), there was a mean response of 3.7 ± 1.0. but the statement "if any disaster (flood, cyclone, landslide) occurs after/during covid-19, the situation will create a double burden to the country" (eei2) was strongly agreed with by 74% of respondents with a mean of 4.65 ± 0.68. 50.4% of respondents agreed with a mean of 4.3 ± 0.84 that "there is a chance of severe food scarcity in the country due to these events (covid-19 + disasters)" (eei3). a strong agreement from participants (varied from 50 to 66%) was observed for the statements: "there is a high possibility of huge economical loss" (eei4) with a mean value of 4.59 ± 0.66, "there is a high possibility of increasing poverty level" (eei5) with a mean value of 4.43 ± 0.78, and "there is a high possibility of severe socio-economic and health crisis" (eei6) with a mean value of 4.48 ± 0.72. the association of affected psychosocial wellbeing and the fragile healthcare system during covid-19 outbreak from the regression analysis, among the 45 variables, only five variables showed statistically significant associations with the fragile healthcare system of bangladesh (hsb1) to deal with the recent outbreak of covid-19 in the country ( table 2) . hsb2, hsb5, and iei1 statistically pose a significant positive effect on the fragile healthcare system of bangladesh (p < 0.01). this relationship implies that a huge population and a lack of healthcare facilities are contributing to the community transmission of covid-19 in bangladesh. the presence of community transmission in bangladesh within a short time is present as predicted by the iedcr, who announced a mildlevel community transmission possibility in bangladesh on 1st april 2020 in their press release (9). this assumption is further validated by the number of deaths from covid-19 reported in the news, after the announcement of the partial lockdown, and the opening of rmg factories from 25 april 2020. the number of covid-19 patients increased significantly in industrial zones. there was also a positive significant association between the fear of the covid-19 outbreak (mh1) with the struggling healthcare system (p < 0.05). also, the negative association between hsb1 and government political decision gpi1 (p < 0.05) reveals that the government is unable to make proper decisions at the right time due to the poor governance in the existing healthcare system. the results of linear regression showed that among the 45 variables, only 10 variables showed statistically significant associations with fear of the covid-19 outbreak ( table 2) . for instance, mental health variables mh2, mh3, and mh4 statistically pose a significant positive effect on fear of the covid-19 outbreak (p < 0.01). on the other hand, there is a statistically positive association between fear of the covid-19 outbreak (p < 0.05)and the healthcare system in bangladesh (hsb1 and hsb8), due to the lack of testing facilities and a fragile healthcare system contributing to the fear that has been experienced due to the covid-19 pandemic in bangladesh. the socioeconomic issues (sei 10) and immediate emerging issues (iei2) have a statistically significant positive impact (p < 0.01), e.g., obstruction to the formal education system, and the potentiality of a huge number of people becoming infected may contribute to the fear development of the covid-19 outbreak in this country. there was also a positive significant association between the chance of community transmission of covid-19 for immediate emerging issues (iei1) with fear of the covid-19 outbreak (p < 0.05). results from the regression analysis further showed eight variables have a significant statistical association with the governance and political capacity to deal with the covid-19 outbreak in bangladesh (gpi1). a significant positive association was found among the governance and political issues (gpi1 with gpi2 and gpi3) and socioeconomic issues (sei2) (p < 0.01), implying that the government's decision to lockdown activities was at the proper time and has enhanced the people's perception of the capacity of government to deal with the covid-19 outbreak ( table 2 ). however, the negative association between governance and political issues (gpi1) and the healthcare system of bangladesh (hsb9) (p < 0.01) shows that a perceived lack of budget created a gap in the response to covid-19 ( table 2) . moreover, a negative association of governance and political issues (gpi1) with the healthcare system of bangladesh (hsb4) and socioeconomic issues (sei3) (p < 0.05) shows a perceived lack of trained doctors and healthcare professionals, and that a hampering of formal and informal business activities are reducing the government's capacity to deal with the covid-19 outbreak. nevertheless, a positive association of governance and political issues gpi1 with socioeconomic issues sei11 (p < 0.05) and governance and political issues gpi7 (p < 0.01) shows that there is a perceived possibility of social conflict due to this outbreak if not managed properly, and that the bangladesh government will need support from developed nations and allied forces to deal with this outbreak. it should be mentioned here that containment, risk mitigation, and suppression plans must be as inclusive as possible or risk undermining response efforts. the regression analysis showed that, among the 45 variables, nine showed a significant statistical association with the future impacts of implementing lockdown and social-distancing activities (sei2). a significant positive association of socioeconomic issues (sei2) with governance and political issues (gpi1) and socioeconomic issues (sei3) (p < 0.01) shows that the government took the right decision by shutting down regular activities and implementing the social distancing approach ( table 2) . but due to this initiative, the formal and informal business sectors and the economy will be hampered. again, a positive association of socioeconomic issues (sei2) with mental health (mh3) and healthcare services (hsb5) (p < 0.05) reveals that this decision of shutting down normal activities was imposed due to the fear of losing lives due to covid-19 and having a lack of healthcare facilities. however, a positive association of socioeconomic issues sei2 with sei4, sei8, sei10, and enduring emerging issues eei6 (p < 0.05) shows that due to this shut down poor people will be severely affected, the price of the basic products will increase, the formal education system will be hampered, and the possibility of severe socio-economic and health crises will increase. in the regression analysis, eight variables are statistically associated with the possibility of community transmission of covid-19 (iei1). a significant positive association between mental health variables (mh1, mh3), healthcare system variables (hsb1, hsb7), socioeconomic variables (sei6, sei11), and immediate emerging issues (iei2, iei3) (p < 0.01) reveals that community transmission will increase the number of infected people which will create further fear and mental pressure of others of losing their lives due to covid-19 infection ( table 2) . the fragile healthcare system of bangladesh will be unable to detect most of the infected patients due to a lack of health facilities, which leads to undermining the actual infected cases. as of the last day of the survey for this study on 30 march 2020, the testing rate of covid-19 was at its lowest in bangladesh compared to the other similar countries (10 people/ 1 million). however, as the laboratories increased, the number of testing has increased along with this, with 878 people/1 million. this is still inadequate compared to the population density. also, the inadequate disposal method of covid-19 hospital bio-medical waste management and associated facilities could increase community transmission. subsequently, due to the community transmission of covid-19, many people will lose their lives and livelihoods, which might lead to creating social conflict, as a worst-case scenario. the regression analysis further identified nine variables that are significantly associated with the possibility of climate-induced extreme natural events (flood, cyclone, landslides, etc.) occurring during/after the covid-19 pandemic. the pandemic along with natural disasters may create a double burden to the country due to enduring emerging issues (eei2). the positive association between eei2, sei9, iei5, eei1, eei3, and eei4 (p < 0.01) shows that there is a perceived possibility of a climate-change-induced disaster after the covid-19 situation which would create severe food insecurity ( table 2) . poor people will suffer most from food and nutritional deficiency and the country will face enormous economic loss. also, after the covid-19 situation, a lack of bio-medical and solid waste management will add more problems. moreover, a positive association between eei2, hsb2, and eei6 reveals that, after the covid-19 emergency, existing poverty will create further socio-economic and health crises. overall relationship assessment among the variables from ctt, pca, and ca ctt and pca revealed a confidence level of controlling factors in bangladesh during the covid-19 outbreak and how these components are correlated to the psychosocial, socio-economic, and environmental crisis components (tables 1, 3) . cluster analysis (ca) further detected the total status of regional variations, and how socio-economic and environmental crises influences psychosocial development (figure 3) . from the ctt analysis, according to the corrected interitem correlation analysis, among 46 variables, four variables have low corrected item-total correlations (i.e., the ability of the government to deal the outbreak, −0.054; seriousness of the government, −0.011; government is taking a proper decision, −0.078; and other sectoral involvement to covid-19, −0.04). the remaining 42 variables in the scale had an acceptable corrected item-total correlation (0.257 to 0.602) and the cronbach's alpha (0.896) was acceptable. from pca, nine principal components (pcs) were originally based on standard eigenvalues (surpassed 1) that extracted 55.28% of the total variance as displayed in table 3 . the scree plot was adopted to detect the number of pcs to be retained to provide insight into the underlying variable internal structure (figure 2) . the loading scores were demarcated into three groups of weak (0.50-0.30), moderate (0.75-0.50), and strong (>0.75) (18) (19) (20) . the pc1 (first) showed 8.967% of variance as it encompassed a confidence level of weak positive loading of the healthcare system in bangladesh (hsb1-3: 0.334-0.459); with results being moderate positively loaded for the healthcare system in bangladesh (hsb4-10: 0.50-0.746). the pc2 (second) indicated 8.587% of the variance and was loaded with moderate positive loading for socio-economic issues (sei5-9: 0.606-0.702 and sei11: 0.548) and weak positively loaded for socio-economic issues (sei2-4: 0.336-0.493 and sei10: 0.418). the pc3 (third) showed 7.196% of the variance and was moderate positively loaded for immediate emerging issues iei1-5 (0.546-0.665). the pc4 (four) indicated 6.792% of the variance, and was loaded with a significant level of strong positive loadings for immediate emerging issues iei4 (0.751); results were moderate positively loaded for immediate emerging issues iei2-3 (0.541-0.683) and immediate emerging issues iei5-6: 0.659-0.686), and were weak positively loaded for immediate emerging issues iei1 (0.345). the pc5 (five) and pc6 (six) indicated 6.023 and 5.603% of the total variances, and loaded a significant level of strong positive loading for mental health issues mhi2-3 (0.764-0.832) and government and political issues gpi2-3(0.783-0.787); results were moderate positively loaded for mental health issues mhi1 (0.746), mhi4 (0.613), government and political issues gpi1 (0.571), and gpi4 (0.698). results were weak positively loaded for mental health issues mhi5 (0.41) and government and political issues gpi7 (0.574). the pc7 (seven), pc8 (eight), and pc9 (nine) showed 5.304, 3.743, and 3.064% of the total variances and were moderate positively loaded for government and political issues gpi5-6 (0.627-0.651), socioeconomic issues sei1 (0.574), sei2-3 (0.636-0.637), and immediate emerging issues (iei1:0.519); results were weak positively loaded for socio-economic issues sei4 (0.397), sei9-10 (0.317-0.322), healthcare sector of bangladesh hsb1-2 in the ca all the parameters were classified into four major groups: cluster-1(c1), cluster-2 (c2), cluster-3(c3), and cluster-4(c4) (figure 3) . c1 was composed of two sub-clusters of c1-a and c1-b; c1-a was composed of issues surrounding an increase in the number of deaths due to not having proper health facilities, a lack of bio-medical waste management facilities in bangladesh that will create more problems, many people experiencing psychosocial issues due to this outbreak, with a large number of people becoming infected, and there being a chance of not detecting most of the infected patients due to the lack of health facilities leading to undervaluing the actual infected cases (iei4-6, iei2-3). c1-b was composed of socioeconomic issues that may lead to poor people suffering from a lack of food, thereby leading to nutritional deficiency (sei2-6 and sei9). c2 consists of socio-economic issues (sei7-11). c3 consisted of three sub-clusters of c3-a, c3-b, and c3-c. c3-a covered governance and political issues gpi5-6, and socioeconomic issues (sei1). c3-b consisted of immediate emerging issues iei1-7, while c3-c was composed of issues related to the healthcare system in bangladesh (hsb1-10). cluster-4 consisted of three sub-clusters of the c4-a health system in bangladesh and immediate emerging issues (hbs9, iei1), c4-b covered mental health issues (mhi1-5), and c4-c contained governance and political issues (gpi1-4 and gpi7). this perception-based study tried to visualize the psychosocial as well as socioeconomic stresses due to the covid-19 pandemic in bangladesh. any major epidemic outbreak has negative effects on individuals and society (14) , and people's fear due to covid-19 is rational in the sense that the fatality rate of the virus is around 1% and it can kill healthy adults along with the elderly or those with existing health problems (21) . it is crucial to assess the covid-19 pandemic independently based on its attributes and not on past epidemics like sars or mers (22) . more than 929 covid-19 symptom-like deaths were reported from leading newspapers and electronic media from 8th of march 2020 to 30th of april 2020. the reported case numbers certainly underestimate the actual number of infected persons given the limited number of urban testing centers, the shortage of test kits, and the long waiting times for tests and test results (9) . the covid-19 outbreak caused other critical care and infectious disease patients to be deprived of basic healthcare facilities. patient-management decisions, early diagnosis, rapid testing, and detection are urgently needed (23, 24) . the decentralization of testing and treatment facilities is required for the healthcare system to combat the pandemic. the government needs to aid in implementing testing facilities in both public and private clinical laboratories all over bangladesh. for a developing country, resources need to be assembled appropriately and promptly. with limited screening and testing of covid-19 in bangladesh, and the presence of only 48 laboratories mostly located in urban areas, it is difficult to predict when transmission of the disease will peak and when the curve will flatten (25) . predictably, community transmission in the country is happening and people are being infected and infecting their community, in some cases even without showing symptoms. it is further predicted that covid-19 and dengue together is a deadly combination. as the monsoon season approaches, the risk of dengue infection is on the rise. it is a timely step taken by the dghs to conduct dengue tests on suspected covid-19 patients, as both diseases share common symptoms (reported on 9 may 2020, by dghs in a daily press briefing on covid-19). successful governance is only possible with a competent early warning system, efficient analysis of the situation, and the interpretation, sharing, and use of relevant knowledge and information (26) . public health instructions should be established based on scientific evidence to reduce the anxiety and distress caused by misinformation and rumors. epidemiological outcomes need to be informed on in time so that they can be accurately evaluated and explained (27) . societies where underserved communities exist strongly fear government information and politics. public risk communications are therefore needed to prevent misinformation from social media and electronic media. the psychosocial risk (mental health impacts) for children in this situation are apparent, as they are out of touch with schools, classmates, and playmates, and deprived of physical activities and social activities; these issues need to be addressed. moreover, the isolation and quarantine of parent/s can mentally traumatize them and result in negligence, mistreatment, and abuse in the absence of parents/caregivers frontiers in public health | www.frontiersin.org (28) . in addition, due to lockdown and the required maintenance of family hygiene, the burden of these activities is increased for women, considering the patriarchal nature of the country (where predominantly all household activities are performed by women). moreover, increased levels of violence against women and girls are experienced, as in the lockdown it is almost impossible for victims to escape those family members who are the perpetrators (29) . furthermore, in the rohingya refugee camps, it will have catastrophic outcomes (3) . these kinds of risks, awareness, and prevention methods should be effectively communicated to the public. as the pandemic continues, each new day brings in new conversations on social media and alarming developments of misinformation and propaganda, resulting in unnecessary psychological trauma and anxiety (30) . moreover, religious tension, personal tension, job insecurity, financial loss, and social insecurity could leave some people feeling particularly vulnerable and mentally unstable (22) . honest, transparent communication is vital for risk communication about the pandemic, while confusing or contradictory health messaging engenders mistrust and leads people to seek information from unreliable alternative sources and thus proliferates rumors (31) . the fear of becoming infected or fear for vulnerable family members has amplified along with the administrative procedures of testing and reluctance of other private clinics and hospitals to admit patients. at the bbginning of this pandemic, bangladesh had only 29 icu beds in five dedicated hospitals in dhaka for the treatment of covid-19 patients. there were no icu beds in hospitals outside dhaka (32) . this is a sign of weak governance in the healthcare system of bangladesh. in this scenario, other critical care patients are denied admittance, experience negligence, and are often left to die without treatment. moreover, the administrative procedure for the covid-19 deceased, whether that be burial or cremation, has created more confusion and religious fear in the minds of the common people. often, family members of the deceased have denied claiming the body due to fear of infection. in those cases, government authorities have intervened. moreover, there is a rumor that the victims of covid-19 are buried without the muslim funeral procedures of bathing, which has created further religious tensions among people. it is, therefore, imperative that the government manages people's fear and anxiety. proper information should be circulated to reduce confusion. the bangladeshi electronic and print media is not acting responsibly to disseminate truthful information and are instead reporting misguided stories on social media. since the 26th of march, the government of bangladesh formed a division to monitor media to eradicate rumors or incorrect information being disseminated on social media platforms and in the mainstream media to protect the mental health of the people. the bangladesh meteorological department (bmd) had forecasted heavy rainfall events and intermittent nor'westers and cyclones at many places across the country during april and may 2020 (33) . heavy rainfall and nor'westers related to high windspeed causes tremendous disasters by destroying standing crops and properties and cause death to people and livestock. fair and equitable sharing of health resources could mitigate further risks to public health by meeting community health needs and generating all-important trust and resilience (31) during further climatic disasters. the development of resilience is significant to combat any disasters, even a pandemic. subsequently, to develop resilience in the healthcare systems and to tackle any pandemic, good governance is crucial, along with good coordination. in addition, it also requires financing, service delivery, medicines and equipment for health workers, and information (34) . moreover, governments, institutions, healthcare facilities, and the general public all hold a social and ethical responsibility to assess and mitigate risks for the most vulnerable communities, including homeless people, people without adequate insurance or employment, indigenous communities, immigrant communities, people with disabilities, and certain frontline healthcare workers and emergency responders. prisons, nursing homes, orphanages, old care homes, homeless shelters, and refugee camps can become focuses for disease outbreaks as these settings often have inadequate access to basic healthcare facilities that increases the disease burden (31) . the government should prepare policies and decisions on early recovery plans which should be inclusive to all ethnic groups, religious groups, minorities, and the wide range of vulnerable populations. april and may are the months of natural disasters like tropical cyclones, tornados, and early flooding in bangladesh, which may be evident within the coming days. therefore, utilization of the health-emergency disaster risk management (health-edrm) framework is important to implement. health-edrm refers to the "systematic analysis and management of health risks, posed by emergencies and disasters, through a combination of (1) hazard and vulnerability reduction to prevent and mitigate risks, (2) preparedness, (3) response and (4) recovery measures" (35) . health-edrm is an umbrella term which the who uses to refer to the broad intersection of health and disaster risk management (drm). as the patients of other seasonal diseases such as dengue are rising, and the possibility of a natural disaster remains, the healthcare system should be coping with the changing scenario of the covid-19 outbreak in bangladesh, where resilience is very important. the hotspot areas of the disasters have already been identified in the bangladesh delta plan 2100 (36) . vulnerable areas should be given special emphasis in the coming months for the protection of crops, risk reduction, relief preparation, and rehabilitation. biomedical waste should be disposed of following national and international guidelines on the disposal of infectious biological hazardous materials (37) . when an exponentially rapid spread of a disease or infection breaks out, the generation of biomedical waste and other related healthcare hazards may be considerably increased within a noticeably short period. if improperly treated, this waste may accelerate the spread of disease and pose a significant risk to medical staff, patients, and waste management unit personnel. a complex short-term decision-making problem is required by the authorities to deal with the fast accumulation and transportation mode of the medical waste. healthcare centers can either directly transport the waste to the treatment centers or they can transfer and consolidate via a temporary transit center (38) . the use of ppe should be distinguished by different risk factors to adopt different epidemic prevention measures and reduce the waste of personal protective equipment, as these resources are already in short supply (34) . moreover, repeated use of disposable masks and not washing cloth masks could create further risk of infection that needs to be dealt with through proper information to the public (39) . as the country does not have proper incineration facilities, the government should think of setting up mobile incinerator plants rapidly to responsibly manage bio-medical waste. as we have analyzed the scenario over the past months of partial, a loss of 33 billion bdt a day to gdp is incurring. more than 10 million people are becoming further marginalized due to the loss of wages and jobs (40) . the dilemma of life vs. livelihoods has put people at high risk of community transmission in the industrial districts after the ready-made-garment (rmg) manufacturers trade organization bgmea decided to open the factories even before the end of lockdown. it was predicted that the government would not get support from the allied forces. weak governance and policy put emergency responders, such as medical doctors and healthcare staff, police, security forces, and army personnel, at risk of infection. already, thousands of doctors and members of the police force have been infected and died during this time. the socio-economic fall-out from this pandemic is already high, particularly for the disadvantaged poor communities, day laborers, wage earners, rmg-sector workers, and small and medium business start-ups. already the country's rmg sector has lost many global orders due to the pandemic, and the remittance flow is at its lowest. job insecurity and financial insecurity is foreseeable, and concerns of a global depression will affect the local market as well as investors. the prime minister of bangladesh already declared a stimulus package of 72,750 crore bdt, of which 30,000 crore bdt has been announced for the rmg sector, other large industries, and the service sector in an attempt to defeat the economic losses due to the coronavirus situation (41) . however, on prioritybasis the financial incentives should be given to the povertystricken disadvantaged communities first, as well as insurance for healthcare professionals at the frontline, emergency responders, and caregivers responsible for emergency handling. purchasing intensive care unit (icu) beds, protective equipment, diagnostic test kits, mechanical ventilators, and additional supports is required for these mentally and physically affected persons who have survived covid-19. it is also imperative to continue taking precautions, including screening, isolation of suspected cases, and social distancing, even after the pandemic is over. finally, combating the global pandemic is not easy. the 46 statements that we have included in this analysis aid in identifying the associations among the psychosocial, socioeconomic, and possible environmental crisis based on public perception in bangladesh. risk mitigation measures concerning the psychosocial, socio-economic, and environmental components of the public are necessary to combat a global pandemic. therefore, with great advancements in the speed and power of science, international collaborations are required to provide knowledge about the virus and disease recovery. moreover, it is highly recommended by who and other stakeholders from the national level to raise the testing speed and facilities in bangladesh. multi-sectoral involvement and proper relief facilities for unprivileged populations must be ensured. without ensuring fundamental needs would be met, the lockdown due to covid-19 has imposed mental stress on the public. the weak governance in the healthcare systems and limited healthcare facilities exacerbated the general public's fear and anxiety. the centralized covid-19 testing facility and limitations of dedicated hospital units for covid-19 patients hampered other critical patients from receiving healthcare services. as a country vulnerable to climate change, there might be some additional risk factors of occurring natural disasters, such as a tropical cyclone, which may add further pressure on the country. the closure of all educational institutions may increase the number of mentally depressed young people. as the business centres (except for groceries, pharmacies, and other daily necessities) are closed, it has put further stress on the country's economy. an infectious outbreak of dengue might be on the way that may have a cumulative/synergistic negative impact with covid-19 on public health in bangladesh. however, numerous factors that can be considered in the context of the current covid-19 outbreak in bangladesh are as follows: risk of community transmission, healthcare capacity, governance coordination, relief for the low-income population, biomedical waste management, and preparation for possible natural disasters. the recommendations collected in the perception study can be summarized as a need to increase covid-testing rates and increase medical facilities. the decentralization of the covid-19 medical facilities is particularly important due to the forced migration of more than 11 million people from dhaka city to 64 districts of bangladesh after the announcement of partial lockdown. in addition, proper risk assessment and dependable risk communication, a multisectoral management taskforce development, care of biomedical waste, ensuring basic support to vulnerable people, and good governance was suggested to reduce the psychosocial and socioeconomic impact of the covid-19 outbreak in bangladesh. finally, this assessment process could help the government and policymakers to judge the public perceptions to deal with the covid-19 pandemic in densely populated lower-middleincome countries like bangladesh. covid-19) situation reports how will country-based mitigation measures influence the course of the covid-19 epidemic? managing covid-19 in low-and middleincome countries countries test tactics in 'war' against covid-19 covid-19 containment: china provides important lessons for global response covid-19: surge in cases in italy and south korea makes pandemic look more likely the fear of covid-19 scale: development and initial validation mitigate the effects of home confinement on children during the covid-19 outbreak available online at available online at doctors at private hospitals left vulnerable. the daily star editorial (2020) hatred and stigmatization grip bangladesh amid covid-19 outbreak student suicide risk and gender: a retrospective study from bangladeshi press reports psychological interventions for people affected by the covid-19 epidemic choosing a method to reduce selection bi-as: a tool for researchers simultaneous comparison of modified-integrated water quality and entropy weighted indices: implication for safe drinking water in the coastal region of bangladesh scale development: theory and applications application of factor analysis in the assessment of groundwater quality in a blackfoot disease area in taiwan characterization of groundwater quality using water evaluation indices, multivariate statistics and geostatistics in central bangladesh characterizing groundwater quality ranks for drinking purposes in sylhet district, bangladesh, using entropy method, spatial autocorrelation index, and geostatistics responding to covid-19 -a once-in-a-century pandemic? a midpoint perspective on the covid-19 pandemic covid-19 and community mitigation strategies in a pandemic emergence of a novel coronavirus disease (covid-19) and the importance of diagnostic testing: why partnership between clinical laboratories, public health agencies, and industry is essential to control the outbreak to withdraw or not to withdraw? tbs news (2020) crippled community governance and suppressed scientific/professional communities: a critical assessment of failed early warning for the covid-19 outbreak in china taking the right measures to control covid-19 covid-19: children at heightened risk of abuse, neglect, exploitation and violence amidst intensifying containment measures covid-19 and violence against women: what the health sector/system can do the covid-19 pandemic: making sense of rumor and fear covid-19: control measures must be equitable and inclusive bangladesh has only 29 icu beds to fight coronavirus! the business standard nor'wester likely this week. the daily star (2020) the resilience of the spanish health system against the covid-19 pandemic building resilience against biological hazards and pandemics: covid-19 and its implications for the sendai framework general economics division (ged) planning and provision of ecmo services for severe ards during the covid-19 pandemic and other outbreaks of emerging infectious diseases reverse logistics network design for effective management of medical waste in epidemic outbreaks: insights from the coronavirus disease 2019 (covid-19) outbreak in wuhan (china) rational use of face masks in the covid-19 pandemic to open or not to open: lockdown exit strategies can help how will the covid-19 stimulus package be implemented? the daily star (2020) available online at all datasets presented in this study are included in the article/supplementary material. the studies involving human participants were reviewed and approved by department of public health and informatics, jahangirnagar university, bangladesh. the patients/participants provided their written informed consent to participate in this study. mb-d, ms, and mr planned the studies and developed the questionnaire. informatics and data analysis and interpretation were maintained by mb-d, ai, ms, and mr. mb and lb revised and improved the manuscript as suggested by the reviewers. all authors reviewed and read the manuscript before final submission. the authors would like to acknowledge all the frontline doctors fighting this pandemic and all the researchers cited in the references. the supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh. 2020.00341/full#supplementary-material the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 bodrud-doza, shammi, bahlman, islam and rahman. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-346358-ffqewqdc authors: dhaggara, devendra; goswami, mohit; kumar, gopal title: impact of trust and privacy concerns on technology acceptance in healthcare: an indian perspective date: 2020-05-11 journal: int j med inform doi: 10.1016/j.ijmedinf.2020.104164 sha: doc_id: 346358 cord_uid: ffqewqdc this paper augments the technology acceptance model (tam) by empirically investigating the influence of behavioral traits (privacy concerns and trust) and cognitive beliefs (perceived usefulness and perceived ease of use) on patients’ behavioral intention to accept technology in healthcare service delivery. despite increased emphasis on healthcare service delivery, there has been limited studies as to how various behavioral constructs are related to adoption of new technology in healthcare sector. to this end, and to develop meaningful insights, a conceptual model integrating behavioral constructs with constructs related to technology acceptance model is devised. the aim here is essentially to understand relationships that predict patients’ acceptance of technology in healthcare services. the devised model is tested on responses obtained from survey of 416 patients availing healthcare service at various primary health centers in new delhi, india. structural equation modeling (sem) is employed to conceptualize the model and validate nine hypotheses entailing key constructs. the results indicate that perceived usefulness, perceived ease of use, trust and privacy concern are direct predictors of patients’ behavior to accept technology in availing healthcare services. in summary, this research provides an empirical contribution to the literature on effect of trust and privacy concerns on acceptance of technology in healthcare. in the declaration of alma ata in 1978, governments across the globe pledged for health for all by the year 2000, emphasizing improved access to primary health facilities and services by setting country specific healthcare targets. however, the targets were missed and considerable gaps in delivering and accessing healthcare services remain, particularly in developing countries (world health statics 2010) . great disparities in terms of measured health inequalities prominently and visibly persist across the developing countries (wagstaff, 2002) . poor in developing countries continue to have minimal access to health services, j o u r n a l p r e -p r o o f resulting in deterioration of health and thus, further aggravating poverty (smith, 1999; peters et al., 2008) . in order to access healthcare services, adoption of technology by patients has often been considered a key enabler for mitigating widespread disparities and poor accessibility (lalseng and andreassen, 2007) . in this backdrop, acceptance and utilization of technology in healthcare service delivery are crucial for both service providers and service consumers (patients). to address the question of adoption of new technology by the consumers, various models and theories have been developed in the past. some of the widely explored theories are theory of reasoned action (tra) (fishbein and ajzen, 1975) , theory of planned behaviour (tpb) (ajzen, 1985) , technology acceptance model (tam) (davis, 1986; davis, 1989) , innovation diffusion theory (idt) (rajagopal, 2002) , unified theory of acceptance and use of technology (utaut) (venkatesh et al. 2003) , technology readiness index (tri) (parasuraman, 2000; parasuraman and colby, 2015) . among these theories, tam is perhaps one of the widely explored models by information science (is) researchers (hwang 2005; venkatesh 2000) . it establishes parsimonious relationships amongst ease of use, usefulness, and intention to use. tam posits that usefulness and ease of use are the major determinants of the end-user's intention to use information technology (it) (davis 1986; davis 1989) . numerous studies have explored impact of technology (mainly it) on several aspects, such as quality, efficiency, and cost of healthcare services (chaudhry et al., 2006) . however, researchers have kept their focus primarily on design and implementation from the service provider's perspective. extant research literature is relatively limited in providing the understanding of the ways in which patients perceive technology usage and how technology is related to behavioral aspects (holden and karsh, 2010) . healthcare being expensive, complex and universally used service, is also one of the most personalized services. (berry and bendapudi, 2007) . building and maintaining trust and ensuring privacy are essential for continued participation of patients in a healthcare delivery system (mandl et al., 2001) . patients are often concerned about possible unwanted economic and social consequences resulting from misuse (or even abuse) of their health-related information (luck et al., 2006) . few studies have augmented original tam model to include the behavioural constructs particularly in context of healthcare delivery (rahimi et al., 2018) . studies have also focussed on qualitative exploration of challenges associated with technology adoption without taking pertinent quantitative analysis into account (pai and huang, 2011) . however, a detailed j o u r n a l p r e -p r o o f empirical study aimed at examination of nuances pertaining to technology adoption by patients in relation to privacy and trust in healthcare, particularly from a patient centric viewpoint (as opposed to service provider centric perspective) is a key contribution of our research. to this end, this empirical study focuses on patients receiving treatment in primary health centers (phcs) in new delhi, india is aimed at answering the following research in order to answer these questions, based on a comprehensive review of extant literature, we propose extending tam by integrating two latent behavioural variables, i.e., trust and privacy concern. this study puts forward a model apt for healthcare services in order to identify relationships between relevant factors affecting intention to use technology by patients. structural equation model (sem) is employed to analyse the structural relationships using survey based responses obtained from 416 respondents belonging to the age group of 18 to 60 years, availing healthcare service at primary health centers in new delhi, india. we contribute to the extant research literature in three ways. first, we focus on acceptance of technology in healthcare from a patient centric perspective. second, we extend the tam framework with behavioural dimensions, aiming to explicate how these factors influence patients' perceived ease of use, perceived usefulness, and behavioural intention to use healthcare services. third, this study reaffirms theoretical foundation of tam in healthcare setup. rest of the paper is structured as follows. section 2 gives details of the relevant literature related to tam and broad domain of healthcare. section 3 illustrates research model and associated hypotheses. methodology is explained in section 4. data analysis and results are presented in section 5. section 6 discusses the analysis and research implications associated with the study. limitation and future research directions associated with the study are presented in section 7. finally, concluding remarks are presented in section 8. the research gaps that we seek to address in this research are related to three key research streams namely, (a) it in healthcare and its adoption, (b) tam, and (c) privacy concerns and trust. now we present the relevant and recent literature for each of these three streams. information technology has transformed ways in which health information are obtained and utilized. based on respective health technology assessments, countries prioritize healthcare delivery in order to create sustainable health systems (littlejohns et al., 2018) . exclusively designed technologies for healthcare services have contributed to the digital health phenomenon (lupton, 2014) . researchers have studied impact of information technology on quality, efficiency and cost of healthcare services (chaudhry et al., 2006) . most of the studies show positive effect of it on healthcare services with some studies reporting mixed findings (buntin et al., 2011) . for example, positive outcomes such as reduced healthcare costs for both service providers and consumers were reported by li and benton, (2006) and increased service satisfaction by queenan et al., (2011) . devaraja et al. (2013) surveyed hospitals in us and substantiated using theory of swift even flow (tsef), the finding that adoption of it results in improved revenue. piccinini et al., (2013) reported reduced costs associated with management of healthcare due to centralization of healthcare service using it. lahiri and seidmann, (2012) reported reduced flexibility as an undesired outcome of technology adoption in healthcare service delivery. sharma et al. (2016) suggested complementarities between clinical health information technologies (primarily used for patient data collection, diagnosis and treatment) and augmented clinical health information technology (used for integrating information for augmented decision making) with respect to process quality. he et al., (2012) identified crucial features of medical sensor networks and introduced relevant node behaviors, including transmission rate and leaving time, etc., within the trust evaluation framework of healthcare delivery. emerging technologies such as big data, cloud computing, block chain and health sensing are revolutionizing healthcare operations and delivery (yang et al., 2015 , wan et al., 2019 and gan et al., 2020 . wang et al., (2016) enumerated a number of capabilities of big data analytics in healthcare sector, particularly for decision support capability, analytical capability for pattern of care, predictive capability, unstructured data analysis capability and traceability. zhong et al., (2016) proposed application of big data analytics for raising adoption of digitized health records. cloud computing as an enabler for cost effective j o u r n a l p r e -p r o o f solution for patient information, sensor-based health data collection and delivery has been proposed in many studies (binczewski et al., 2011; patra et al., 2012; rolim et al., 2010) . available literature on adoption of technology in healthcare can be broadly categorized in two streams. first, studies concerned with extent of it related adoption in healthcare by analyzing pervasiveness, scope and scale. second, studies examining enablers and barriers in adoption of it (agarwal et al., 2010) . studies belonging to first stream have explored various characteristics of healthcare service providers, such as size, location, competition, ownership status, etc., that have adopted it (cutler et al., 2005; jha et al., 2009; kazley and ozcan, 2007; mccullough, 2008) . major barriers in adoption of it as enumerated by second stream of studies include financial, functional, environmental and individuals including service providers and service users (bhattacharjee et al., 2006; desroches et al., 2008; jha et al., 2009; tang et al., 2006) . one key challenge with adoption of it in healthcare is that the systems are typically not designed for multi-institutional lifetime records. ethically managing health data, guarantee of security, auditability of records, and interoperability and immutability are few concerns that need to be addressed (ekblaw et al., 2016) . qadri et al., (2020) in their study of emerging technologies for healthcare delivery advocated for iot (internet of things) and ai (artificial intelligence) oriented healthcare delivery system. further, this study conceptualized the tenets of h-iot (healthcare internet of things). the arguments for adoption of h-iot was also supported by porambage et al., (2016) . meng et al., (2018) in their surveyed stakeholders belonging to 12 different healthcare organizations developed a trust-based approach to figure out malicious devices in a healthcare environment. yan et al., (2015) proposed trust based framework for virtualized networks and softwaredefined networking. the study in particular argued for adoption of cloud computing to securely deploy various trustworthy security services over the virtualized networks. ahmed et al., (2017) explored the recent advances in big data analytics for iot systems as well as the key requirements for managing big data and for enabling analytics in an iot environment. lin et al., (2018) presented a blockchain-based system for secure mutual authentication to enforce fine-grained access control polices. proposed two trust evaluation algorithms to support different application cases. specifically, these algorithms can overcome attacks raised by internal malicious evidence providers. perera et al., (2017) argued for adoption of fog (edge) computing based approach for solving analytical and computational problems for diverse problems including those related to medical industry and smart cities. wazid et al., (2017) devised a novel authentication framework for medicine j o u r n a l p r e -p r o o f anticounterfeiting system considering the iot environment aimed at ascertaining the authenticity of pharmaceutical products. the key benefit of the proposed scheme was in terms of its lower communication and computation cost over other similar authentication schemes. wazid et al. (2018) proposed a new secure remote user authentication scheme for implantable medical devices communication environment to overcome security and privacy issues associated with existing schemes. there has been effective evolution and acceptance of technology globally since second half of 20 th century. this has resulted in improvements in social lives, interpersonal relationships and even self-expression (gucin and berk, 2015) . tam, as a research stream, is a widely deployed model for accessing acceptance of technology in information systems because of its simplicity and understandability (king and he, 2006) . its proponents articulated that the key to enhancing use was to first increase acceptance of it, which could be assessed by measuring individuals' future intentions to use (davis, 1986; davis, 1989; davis et al., 1989) . the model is based on the theory of reasoned action (tra) (fishbein and ajzen, 1975) , a psychological approach that illustrates how individual's belief system mediates human behavior. tra theorizes that behavioral intention (bi) of an individual to use a product or a system is decided by the individual's attitude and subjective norms related to the behavior. tra assumes behavioral intention to be closely linked to actual behavior. in comparison to tra that explains many divergent human tendencies, tam focuses on a particular kind of behavior, i.e., the rational acceptance of technology by the technology user (davis, 1989) . tam involves two primary concepts namely perceived ease of use (peou) and perceived usefulness (pu) to influence dependent variable behavioral intentions (bi) (king and he, 2006) . pu and peou are defined in the following way: perceived usefulness (pu)-"the degree to which a person believes that using a particular system would enhance his or her job performance" (davis, 1989, p. 320) . perceived ease of use (peou) -"the degree to which a person believes that using a particular system would be free of effort" (davis, 1989, p. 320) . tam has been studied in different contexts with different technologies (e-mail, world wide web, hospital information systems, etc.). it has been applied with different control factors such as organizational size, type, gender, etc., on different subjects such as undergraduate j o u r n a l p r e -p r o o f students, mbas, and knowledge workers resulting in establishment of robustness among its proponents. tam has received enormous empirical support in elucidation and prediction of technology acceptance and use in various settings (dabholkar, 1996; dabholkar and bagozzi, 2002, and . divergent external factors such as training, compatibility, anxiety, computing support, experience, relevance, personal innovativeness, etc., have been studied in context of tam (lee et al., 2003) . tam has also been applied to study various aspects in healthcare services. online disability evaluation systems, personal digital assistant for healthcare, telemedicine technology, electronic health records (ehr) and mobile applications are few of them. adoption of e-health monitoring using smart wearable healthcare devices has been one of the recent contributions to extant research literature (li et. al, 2016; papa et. al, 2018; wu et. al, 2011; zhou et al., 2019) . rahimi et al. (2018) employing a systematic literature review approach identified three ict application areas namely, telemedicine, electronic health records, and mobile application for tam in healthcare service delivery. the literature review also reported of a few studies wherein mediating role of behavioural aspects in conjunction with other factors such as mobile health, etc., were investigated. with ever increasing competition and growing personalization of markets, service providers are increasingly focusing on understanding the consumers (patients) better, thus leading to proliferation of consumer information. although, most consumers welcome the increased convenience and personalization as natural outcomes, many remain concerned about privacy associated with their personal information (lanier and saini, 2008) . privacy concern has been typically defined as concern for loss of privacy and need for protection against uncalled-for communication and misuse of personal information (smith et al., 1996) . it concerns with being in control of personal information exchanges and security, and whether the beholder of the information will use it appropriately (lanier and saini, 2008) . xu et al. (2008) suggested that privacy concern is the result of individual's outlook to privacy and circumstantial cues that enable him/her to assess the outcome of information disclosure. dinev and hart (2005) argued that perception of privacy develops socially through transactions with social entities. cognitive processes of identifying information boundary comprising of privacy risk, privacy intrusion and privacy control is vital for structuring the privacy concerns of an individual. the demographic factors such as age, gender, income status affect privacy concerns of consumers (culnan and armstrong, 1999) . individuals are found more concerned about their j o u r n a l p r e -p r o o f privacy when information is used without their knowledge or permission or when intended use of the information is not revealed (phelps et al. 2000) . these attributions have also been concluded and validated empirically in various models (phelps et al. 2000, chellappa and sin 2005; dinev and hart 2006) . for some, protection of patients' information is part of core professional ethics and for others, it is simply occupational work in the interest of organization (anthony and stablein, 2015) . research on addressing privacy concerns of consumers has grown considerably in the recent past and shifted from general contexts to specific ones (yun et al., 2019) . researchers have explored privacy concerns in diverse fields like social networking (heravi et al., 2017; jeong and kim, 2017; lankton et al., 2017) , online services hart, 2005, jiang et al., 2013) , healthcare (bansal et al., 2010; xu, 2019) , location-based services (xu et al., 2011; zhou, 2011) . studies have explored a large number of antecedents of privacy concerns. li (2011) categorized these antecedents into five groups on the basis of their level of study. these are individual factors, socio-relational factors, macro-environmental factors, organizational and task environment factors, and information contingencies. studies have conceptualized various instruments and models for privacy concerns in different contexts. for example, the concern for information privacy (cfip) (smith et al. 1996) conceptualizes organizational privacy practices. internet users information privacy concerns (iuipc) (malhotra et al. 2004 ) operationalizes multidimensional notion of internet users' privacy. however, for our study in healthcare services, we use model suggested by xu et al. (2008) . this model explains molding of individual's privacy concern towards specific practices through a cognitive process comprising of privacy control, privacy intrusion and perceived privacy risk. drawing on information boundary theory, this integrative model implies that the individual's disposition to situational or privacy indications thus enabling them to assess consequences of their information disclosures shape the privacy concern of the individual. trust, on the other hand, has received a great deal of attention in sociology, social psychology, economics and as well as in marketing field. it is an elusive multiplex concept (castaldo et al. 2010 ) and a multi-dimensional construct with two inter-related components, i.e., trusting beliefs and trusting intentions (mcknight et al., 2002) . rousseau et al., (1998) defined trust as "a psychological state comprising of the intention to accept vulnerability based upon positive expectations of the intentions or behavior of another under conditions of risk and interdependence". trust is essentially needed in uncertain situations, since it j o u r n a l p r e -p r o o f eventually implies accompanying risks and becoming susceptible to trusted parties (hosmer, 1995) . it has been identified as a catalyst of transactions providing service receivers with expectations of fruitful exchange relationship with service providers. drawing on various literatures, doney and cannon (1997) defined trust as perceived credibility and benevolence of a target trust. here credibility refers to the extent to which the receiver believes that the service provider has the required expertise to perform the job effectively and reliably. whereas, benevolence refers to extent to which the receiver believes that the service provider has the intentions and motives beneficial for the receiver in unforeseen conditions for which commitment is not made (ganeshan, 1994) . schoorman et al., (2007) contended that all three factors related to integrity, ability, and benevolence could affect trust in a group or organization. consumers' loyalty, long term relationships, commitment and product acceptance are underpinned by their trust in service providers (bozic, 2017) . trust plays a crucial role in virtually all shared economy interactions (hwlitschek et al., 2018) . in online domain, it often functions as the sole foundation for the consumers to take purchase decisions in case of scarce information (bleier and eisenbeiss, 2015) . gefen et al., (2008) called for reexamination of dimensionality of trust in context of online environments. they argued that besides existing methods like case studies, field interviews, surveys, econometric analysis, experiments, analytical modeling etc., for examining trust, other techniques like cognitive neuroscience too can be deployed for better understanding of nature, antecedents and consequences. söllner et al., (2016) reasoned that survey-based approaches postulate valuable insights about the interrelations of diverse trust concepts in is literature. these are frequently applied to distinguish between targets of trust that determine is use. in order to study technology acceptance in healthcare with respect to trust, we need to appreciate distinctions of healthcare services from other services. people commonly demand healthcare services under distress in that either they are sick or at risk thus relinquishing privacy. there is risk of loss of privacy associated with providing personal information (culnan and armstrong, 1999) . if the service provider cannot be trusted, there is no reason why consumers should expect to gain from using the particular service (paulov, 2003) . number of public opinion polls establish that individuals are quite concerned about threats to their personal information (xu et al., 2008) . however, partial mediation of trust and privacy concern reduce the perception of risk (andrews et al., 2014) . once consumers trust the j o u r n a l p r e -p r o o f service provider, the service provider seeks more health-related information (miller and bell, 2012) . bansal et al., (2010) established that personal disposition indirectly impacts trust through information sensitivity and privacy concern. platt et al. (2019) found that expectations of benefits and positive views of health information sharing are associated with system trust. steininger et al., (2015) in their study pertaining to acceptance of electronic health record (ehr) demonstrated that privacy concerns impact perceived usefulness of ehrs negatively. he et al., (2012) identified the security challenges facing a sensor network for wireless medical monitoring and suggested that the network should follow a two-tier architecture. based on such an architecture, the study also devised an attack-resistant and lightweight trust management scheme termed as retrust. zhou et al., (2013) likewise, researchers have extensively explored behavioural constructs namely, trust and privacy concern, their enablers and their influence on technology acceptance independently in online transactions and e-commerce applications. however, studies on effect of behavioural aspects of patients on acceptance of it in healthcare are lacking. because of various distinct characteristics of healthcare service, it would be fruitless to apply canonical approaches for assessing users' response by espousing inferences from studies carried out in other service setups. in this section, we present research model that encompasses elements affecting behavioral intentions of healthcare service users to adopt technology. researchers have widely explored it in healthcare from the perspective of associated merits and limitations within the sector. extant studies, primarily, have focused on enablers and barriers in implementation of it in healthcare sector from service provider's perspective (agarwal et al., 2010; dey et al. 2013; mccullough et al. 2010) . we find limited studies on adoption of technology concerning patients' perspectives. in this study, we extend tam from patient centric perspective by incorporating variables such as patients' cognitive belief, trust and privacy concerns in addition to tam variables. to this end, following hypotheses are conceptualized. perceived usefulness is the degree to which the consumer perceives a service useful, while perceived ease of use is the consumers' perception about effortless use of the service system (davis, 1989) . consumers evaluate usefulness of a service based on what they get and what they pay for it. similar to other services, within healthcare services as well, the patient strives for timely and right treatment without much burden on his/her resources. if the patient perceives that any technology can help in getting effective treatment, the patient is more likely to avail the service facilitated by that technology. similarly, given major parameters remaining same, if patients are provided with option to get themselves treated at any place without physically carrying their case history and using technology as facilitator, they would most likely gravitate towards accepting the technology. further, ease of use is vital for acceptance, as familiarity with technology and skills to use technology are likely to vary significantly within the diverse population. there is extensive literature that has established that perceived usefulness and perceived ease of use directly and positively influence behavioral intention to use. perceived ease of use also influences indirectly through perceived usefulness (dabholkar, 1996; dabholkar and bagozzi, 2002; davis, 1989; szajna, 1996; venkatesh, 2000) . therefore, in line with these arguments and extant literature, we hypothesize the following. in e-commerce and is literature, trust has been widely acknowledged in influencing user behavior in adoption of technologies (amoako-gyampah and salam, 2004; ha and stoel, 2009; paulov, 2003) . healthcare delivery, however, is more personalized and vital service for consumers (berry and bendapudi, 2007) . the patient has to give access to personal information and previous health records to the service providers. extant studies have established an array of divergent aspects in delivery and patients' ability to evaluate healthcare services (mcglynn et al., 2003) . healthcare is one such typical service, wherein efficacy of primary service availed (treatment) cannot be evaluated or verified even after consumption of service. hence, the consumer has to solely rely on the diagnosis made by the j o u r n a l p r e -p r o o f service provider. handing over personal details to the service provider is predicated upon trust, a vital factor in acceptance of technology in healthcare services. trust is one of the defining factors in such exchanges, where uncertainty is present. practically, trust is a prerequisite for interactions conducted in uncertain environment (ba and paulov, 2002) . in such situations, beliefs about the service provider (apart from usefulness and ease of use) also becomes crucial. if the service providers fail to convey trustworthiness, the consumer is not likely to engage in transaction (hoffman et al. 1999) . similarly, in case of healthcare, if the patient trusts the healthcare provider to fulfill his or her needs, then the patient is more likely to view technology as beneficial for him or her (lalseng and andreassen, 2007) studies have supported trust as a vital construct for predicting acceptance of technology (carter and bélanger, 2005; gefen et al., 2003; parasuraman et al., 2008; paulov, 2003) . studies have theoretically and empirically supported integration of trust with tam constructs. if service provider cannot be trusted by the consumer, the consumer is not likely to see any usefulness in the service provided. at the same time, trust on service provider will reduce efforts needed to verify, monitor and control the service interaction. on the other hand, if trust is low, consumer would be forced to devote more time and effort to gauge the service thus to avoid any opportunism on part of the service provider. therefore, in line with the existing literature, we hypothesize the following hypotheses. j o u r n a l p r e -p r o o f researchers have studied privacy extensively. privacy concern (pcon) has been one of the most widely used variable amongst privacy related constructs in is research. it has been one of the strongest predictors of the privacy related behavior (dinev and hart 2006; malhotra et al. 2004; stewart and segars, 2002) . capturing nuances related to privacy have gained significance, as it is increasingly expanding capabilities to store, process, explore and exploit personal information (dinev and hart, 2005) . despite growing research interest in privacy concerns, there are lack of empirical evidences as to how privacy concerns affect acceptance of technology in healthcare. privacy concern (a part of our proposed model) is considered a direct determinant of bi. the rationale is extracted out of the existing studies carried out in different domains. existing literature suggests that privacy concerns make users circumspect about using technology and sharing personal information. in sensitive areas, privacy concern of health information may even cause individuals to avoid obtaining certain healthcare services. if privacy concerns of the customer are not mitigated by the service provider, it will have significant negative effect on the consumer's attitude and behavior towards the service (milne and boza 1999; phelps et al. 2001) . in an empirical study on internet uses, dinev and hart, (2005) also found out negative impact of privacy concern on intention to use. privacy of the personal information is the focal concern of the individual (stewart and segars, 2002) . mukherjee and nath (2007) identified that security to privacy along with shared values positively influences behavioral intentions of the customers. this study follows the perception that privacy concerns measure the patient's assessment of lack of reliance on the service provider, especially when one has to share personal details. therefore, in line with the above presented arguments, we hypothesize the following. though various researchers have explored privacy in different contexts and environments, we found a few literatures on the effect of privacy concern on pu and peou. andrews et al., (2014) asserted that higher privacy concerns negatively mediate the relationship between perceived risk and attitude of the user. intuitively, we can argue that patients will not find usefulness in a technology that is likely to invade their privacy. individuals are likely to put more effort into monitoring if they feel that their privacy is at stake while using any service. therefore, concern for the privacy of the user will reduce the ease of use and will affect j o u r n a l p r e -p r o o f his/her perceived usefulness for any service negatively. along these arguments, we hypothesize the following. to test our model, we have adopted survey-based strategy consisting of structured selfadministered questionnaire. we considered five latent constructs and twenty-three manifest variables to measure them. methodology of research is summarized in figure 2 . data for testing hypotheses has been collected using scenario and questionnaire-based approach. the respondents were given a scenario (presented in appendix 1) before responding to the questionnaire. this approach is adopted as healthcare services linked to unique identity that does not yet exist in targeted area. however, validity of the response of individual based on a scenario has been well documented by bem (1967) . to make the scenario as realistic as possible, it was discussed with the patients in primary health centers. based on the inputs presently available electronic healthcare record systems are not designed to manage multiinstitutional, multi-format lifetime health records of patients. patients leave their health data scattered across various health service providers wherein they have availed treatment. these healthcare providers work in silos and hardly any inter-organizational data transfer takes place. whenever a patient visits any healthcare provider, either the patient carries the related previous records (in the form of case history) obtained from previous healthcare providers, or the case is registered as a fresh case. in such redundant process, lots of scarce resources that could have been provided to a new patient, are used on the same patients repetitively. to facilitate availability of medical records, we propose that healthcare records to be linked to unique identity (aadhaar -unique identification number for the citizen of india) of the patient. these records can be accessed at any health center by patients providing authentication of their unique identity. aadhaar, a 12-digit unique number allotted to the citizen of india, stores demographic, biometric and financial information of the individual. aadhaar number can be used as an identity and has been made mandatory for availing benefits of many governmental social schemes. as aadhaar number is linked to personal and financial information, sharing aadhaar identification can raise apprehensions about safety and security of data in the mind of individual. scenario for collection of data has been literature review on tam, trust and privacy concern development of conceptual model and hypotheses development of scenario development of questionnaire cfa and sem of collected data analysis of results and its implications j o u r n a l p r e -p r o o f developed highlighting concern of sharing aadhaar identification with healthcare provider (see appendix 1). as argued by pai and huang (2011) , we designed our questionnaire on a five point likert scale with 1 being "strongly disagree" to 5 being "strongly agree" to collect data on demographic profile of respondents and twenty-three manifest variables. all items were adopted from published sources to ensure psychometric properties (internal consistency, testretest reliability, factor structure etc.). these measures were adjusted in consonance with healthcare environment. experts in the field of operation management examined the questionnaire for its clarity, terminology, logical consistency and contextual relevance. constructs, observed variables, questions and their sources are presented in table 1 . questionnaire was prepared in english and hindi (local language). a pilot study was carried out on 25 respondents, who had visited delhi government's dispensaries in the recent past. respondents were asked to give comments on wording and relevance of the questionnaire items, length of survey, difficulty, if any, in answering and time taken to complete it. based on qualitative assessment of their comments, language of the questions was simplified to make them more understandable and eliminate any ambiguity. in delhi, both government and non-government organizations provide healthcare facilities. we randomly selected 11 dispensaries from 8 out of 11 districts of delhi for data collection. patients and their accompanying member(s), both females and males, in the age group of 18-60 years were approached. patients seemingly in critical medical state were not disturbed. consent from the respondents was taken before asking for their response. respondents were asked to read the scenario before giving responses. few, who were not willing to read the scenario, were personally explained. 458 responses were received. on scrutiny, 42 responses were rejected due to incomplete or multiple responses. in all 416 responses were statistically analyzed for verification of our conceptual model. demographic characteristics of the sample are presented in table 2 .1 and descriptive statistics are presented in table 2 .2. careful observation of the descriptive statistics presented in table 2 .2, indicates that on an average, perhaps, mean related to privacy related items are lowest as compared to items pertaining to trust, pu, peou, and bi. further, within privacy related items itself, perhaps pcon1 has the lowest mean, implying that respondents in general are already concerned about the providing much personal information. i am concerned about giving information to health providers. healthcare service providers are trustworthy. paulov (2003) t2 healthcare service provider is one that keeps promises and commitments. i trust healthcare service provider because they keep my best interests in mind. utility (pu) aadhaar linked healthcare services will enable me quick service. davis (1986) , davis (1989) , davis, bagozzi and warshaw (1989) pu2 using aadhaar linked healthcare services will increase productivity of service provider. aadhaar linked healthcare services will improve performance of service providers. using aadhaar linked healthcare services will enhance effectiveness of service providers. using aadhaar linked healthcare services will make it easier to get healthcare services. overall, i find aadhaar linked healthcare services system useful for me. learning to get healthcare services using aadhaar will be easy for me. davis (1986) , davis (1989) , davis, bagozzi and warshaw (1989) peou2 it will be easy to get healthcare service using aadhaar based service. it will be easy for me to remember how to get required service using aadhaar based healthcare service. my interaction with healthcare service providers is clear and understandable. i find [that it will not] take a lot of effort in using healthcare services. overall, i find the aadhaar based healthcare service will be easy to use. intention ( the non-response bias in this study was also tested by performing a series of t-tests between the last twenty five percent of respondents and the rest of the sample on a large number of variables in the survey following the framework developed by armstrong and overton (1977) . as the data was collected from single respondents, there is also an accompanying risk of spurious covariance between the measures in the survey, i.e., common method variance (cmv) possibly resulting in biased estimators (siemsen et al., 2010) . step was taken to minimize cmv and limit its potential effect on the analysis. the wordings of the survey items were refined to improve their clarity by using expert judgment (in this case by both academic and industry expert) and q-sort techniques, resulting in tentative item reliability and item validity (menor and roth, 2007) . evaluation of quality of measurement model is the primary stage of any structural equation modeling involving examination of convergence, content and discriminant validity, and reliability of constructs. since all the items are adopted from published research literature and experts in the field conducted item-by-item evaluation before and after the pilot study, content validity of the measurement is established (straub et al. 2004 ). construct validity is established by ascertaining convergent validity and discriminant validity. factor analysis with j o u r n a l p r e -p r o o f varimax rotation using spss16 is carried out to ascertain convergent validity. kaiser-meyer-olkin measure of sampling adequacy value is 0.92, higher than justifiable value for carrying out factor analysis (0.5) (kaiser, 1974) . bartlett's test of sphericity is significant (table 4 ). all the items displayed clear loading unto their five respective components as given in table 5 . average variance extracted (ave) for all constructs and quality parameters, i.e., cronbach's alpha, composite reliability (cr) are reported in table 3 . all measures representing constructs have cronbach's alpha above the acceptable limit of 0.70, cr above 0.7 and ave more than 0.5 (cortina, 1993) confirming convergent validity, discriminant validity and reliability of the constructs. sig. .000 we use sem for analysis of the proposed measurement model. use of sem will substantiate robustness of findings as it is based on maximum likelihood algorithm that considers error terms in establishing loadings, correlations and other related measures. the measurement model is evaluated on primary fit criteria, overall model fit and fit of internal structure of model as proposed by bagozzi and yi (1988) . widely accepted and reported fit indices including absolute fit, incremental fit and parsimony fit indices of the conceptual model are examined (hooper at al., 2008) . absolute fit measures, i.e., chi-square static, gfi (goodnessof-fit index), agfi (adjusted goodness-of-fit index) and rmsea (root mean square error approximation) determine degree to which the overall model predicts the observed covariance or correlation matrix. incremental fit indices, i.e., nfi (normed fit index), cfi (comparative fit index) and nnfi (non-normed fir index) compare the proposed model to j o u r n a l p r e -p r o o f baseline model, often referred to as null model. pnfi (parsimonious normed fit index) and pgfi (parsimonious goodness-of-fit index) are termed as parsimony fit indices. these indices determine impact of additional parameters on the conceptualized model. all the indices of the proposed model obtained using lisrel are within acceptable limit are presented in table 6 . all the fit indices were within acceptable limit indicating good model fit (mcdonald and ho, 2002; mulaik et al., 1989; pai and huang, 2011; schreiber et al., 2006) . path coefficients along with t-statistics of corresponding hypothesized paths are presented in table 7 and figure 3 . seven path coefficients are found considerably high and statistically significant. as per the established tam, pu is found to influence bi and peou to pu. peou influence on bi found to be insignificant. trust influence on peou is not found significant, however, trust has direct influence on pu and bi. privacy concern is found to influence pu, peou and bi negatively. the obtained results from our empirical analysis support proposed hypotheses on acceptance of technology in healthcare. however, the significance of individual hypotheses warrants further discussion. this research examines technology acceptance in healthcare services, hypothesizing and validating role of trust and privacy concerns. in addition to reaffirming relations of original tam constructs, our results elucidate that trust and privacy concern directly affect patients' intention to use technology in healthcare services. growing interest in patients' reaction to introduction of technology in healthcare has given impetus to theories that predict and explain technology acceptance and usage. the results suggest that while enhanced trust positively affects behavioral intention and perceived utility of the service, privacy concern, on other hand, has negative effect on behavioral intention, perceived utility and perceived ease of use of medical services. in particular, the studies carried out by andrews et al., (2014) and honein-abouhaidar et al., (2020) are important to be discussed here, since both of these studies, investigated the acceptance of technology by people availing healthcare services. andrews et al., (2014) , while investigating australian general public perception of adopting a personally controlled electronic health record (pcehr), argued that individuals appreciate the value associated with pcehr. however, adoption of pcehr was explained by perceived value and perceived risk. further, individuals also liked to have two key concerns, viz., reduction in privacy and lack of trust to be mitigated before committing to pcehr. however, how and to what degree trust and privacy concerns impact the behavioral intentions of individuals is something ascertained by our study. unlike the study by andrews et al. (2014) , our study also considers the relationships amongst behavioral constructs and perceived utility associated with adoption of technology in healthcare delivery. trust does not seem to have significant effect on ease of use of any technology in healthcare. all hypotheses are confirmed through empirical assessment. the results also confirm findings of similar studies carried out in online services. however, evaluation of effect of trust and privacy concern on technology acceptance in healthcare services provides the aspect of originality in respect of existing literature. our results in regard to behavioral intention also somewhat support the findings from honein-abouhaidar et al., (2020) arguing that positive relationship exists between perceived utility and behavioral intention in adopting electronic patient portal (epp). our study supports earlier literature on trust and transactions and confirms their relevance in healthcare services also. data from primary health centres shows that trust has direct bearing on behavioural intentions of patients to use the service or avoid to it. the study also establishes positive relationship between trust and perceived utility. based on these results, we can assert that trust is an enabler of acceptance of technology in healthcare services. the results also demonstrate that privacy concerns of patients are negatively associated with perceived utility, perceived ease of use and as a result behavioural intention of adaptation of new technology in healthcare. our results support previous studies, carried out in different services, which suggest that if consumers' privacy concerns are not mitigated, they will have negative impact on consumers' decision on availing that service (eastlick et al., 2006) . given the potential repercussion on consumer's attitude, it is essential j o u r n a l p r e -p r o o f that researchers accurately understand the concern related to consumer's information privacy. above analysis synthesizes the assertion that privacy concern is an inhibiter of acceptance of technology in healthcare services. following implications can be clearly derived from the research analysis discussed above. from managerial point of view, major implications of this study can be summarized as follows. firstly, in today's technologically intensive and competitive health care domain, the citizens' need (particularly in developing countries) is oriented around high quality care at an affordable cost. health care managers, therefore, must find cogent ways to obtain superior healthcare results considering rather limited resources. secondly, as numerous studies have shown that adoption of new technologies in healthcare can provide quality healthcare to all socioeconomic strata of the society particularly in rural and remote areas, it is pivotal for healthcare service providers to understand the driving forces of patients' acceptance of technology. this study demonstrates factors that affect behavioural intentions of patients in acceptance of newer technologies. thirdly, this study reflects needs for strategic planning, assessing and understanding the role of trust to allay ethical concerns related to the user sensitive data. finally, success of any e-health program hinges on acceptance of technology to put in place robust it enabled models designed for providing access to affordable healthcare. it mandates service managers to strive for greater technology acceptance amongst patients. on theoretical front, this research provides significant contributions in establishing link between behavioral aspects and acceptance of technology in health services. the study explores a vital issue of patients' trust and their privacy concerns in context of new technology acceptance, thus providing a theoretical foundation to understand behavioral responses of patients on introduction of a new technology in healthcare service delivery. additionally, our study also contributes to the extant literature by proposing and testing extended tam by integrating behavioral constructs in healthcare context. adapting to the conceptualization of trust and privacy concern in various other services, this research reaffirms effect of these constructs on acceptance of technology in healthcare services. this approach will help us in building a holistic picture of technology acceptance in healthcare. this study suggests that perceived usefulness, perceived ease of use, trust and privacy concerns are valid predictors of technology acceptance in healthcare service delivery. our study lends support to theoretical foundation of tam in healthcare setting associated with credence, co-creation and co-production, and vulnerability of service receiver as few key attributes. partly, implementation of new technology in healthcare is marred by lack of engagement of the service consumers. theoretically, existing literature is rather inadequate in satisfactorily exploring contingent factors emerging from application of smart technologies in public healthcare (papa et al., 2018) . this study provides relationship between an individual's behavioral constructs and final acceptance of technology in healthcare service setting. countries have been spending significantly on new technologies for improving healthcare service delivery. however, when adopted technology is not acceptable to the patients, then the purpose of these technological advancements gets defeated. despite notable gains in improving life expectancy, improving maternal and child mortality outcomes and addressing other health priorities, the rate of improvement has been far from satisfactory (particularly in developing world). for policy makers and researchers, this study does a redressal of four issues to obtain acceptance and desired outcome of technology being introduced in healthcare services. firstly, introduced technology must focus on expected usefulness to the patients. secondly, service providers must focus on ease of use and convenience associated with the technology. thirdly, trust has been found to impact patients' perception of utility and thus, behavioral intention to use that technology. while expected use and ease of use can be explained to the user, trust is something, which has to be earned. onus here lies with implementing agencies (health centers in this case) and the governments to develop trust amongst patients for delivery of healthcare services. finally, privacy concern has influence on utility, ease of use and final acceptance of any technology. like trust, apprehensions related to privacy concern of the patients have to be mitigated by the implementing agencies and the government. technology induction in healthcare will not only create value for patients, but also for the entire social and economic ecosystem. in india, availability of enabling technologies like mobile internet, cloud computing and social media augmented by favorable demographics and healthcare infrastructure can create a fertile ground for induction of technologies in health care delivery. various governmental direct benefit schemes are already linked with aadhaar numbers of citizens. however, j o u r n a l p r e -p r o o f healthcare services are yet to be linked to any unique identity in the country. one such study proposed blockchain and big data assisted, unique id linked model for universal healthcare coverage (dhagarra et al., 2019) . as an augmentation to dhagarra et al., (2019) , this research delineates behavioral factors to be considered while implementing any technology assisted healthcare model for achieving universal healthcare coverage. as already ascertained by extant studies (andrews et al., 2014) , mitigating privacy related concerns in patients' minds thus ensuring enhanced trust between patients and service providers, is crucial to success of medical services delivery including e-services. in this regard there are certain concrete steps can be taken by the concerned stakeholders including both government and healthcare providers. in indian context and on a governmental level, of particular interest would be hipaa (health insurance portability and accountability act of 1996) and eus safe harbor law (barua et al., 2011) . these laws usually mandate strict security measures for sharing and exchanging health data, and failure to comply with them is accompanied by severe penalties. from the standpoint of health care service providers, only authorized users such as medical staff should have access to the collected health data as it almost always contains confidential and sensitive data. this security critical system, however, requires careful balancing between confidentiality and availability. the dichotomous nature of these two goals is clear: while all the patient's data should be available to be shared and monitored to deliver professional healthcare services; for security reasons, part of the data may be considered confidential and therefore must not be accessible. clearly, rationalization of the paired goals should be achieved to provide the best possible care for patients. further, when dealing with privacy concerns in e-healthcare models, security models revolving around data collection, data transmission, and data storage would have to be designed carefully (zriqat et al., 2016) . of particular interest in this context would be use of blockchain concept for patients' registration and handling of medical record as proposed by dhaggara et al., (2019) as a way of creating immutable and secure framework. to the best of authors' knowledge, this is first study aimed to explore technology acceptance linking unique identity with healthcare records in india. since such conceptualization is yet to be implemented, there exists many limitations in our study. we recommend a pilot project implementing integration of healthcare records based on unique identity. this study has been carried out in urban area of one city of the country wherein the respondents were relatively j o u r n a l p r e -p r o o f young and educated. educated respondents therefore pose less of a challenge as far as interpretation of survey responses are concerned. though data has been collected by randomly selecting healthcare centers and patients, it may not reflect huge diversity of the population. to further validate present findings, proposed model may be investigated in different countries in different geographical spreads. model may further be cross validated in developing and developed countries. this will further boost the reliability of results and may result in some degree of generalization of managerial and theoretical inferences. to further boost robustness and validity of the proposed model, study may be replicated with larger sample size and at different levels of healthcare services like in specialty hospitals. finally, the study investigates effect of only two additional behavioral constructs on technology acceptance in healthcare delivery. future study may include more behavioral constructs to study their effects on technology acceptance in healthcare. of particular interest would be to include behavioral constructs that can explain patients' behavioral and psychological traits in the time of pandemics (for instance the ongoing covid-19 situation). psychological interventions for all or specific (e.g., more vulnerable) groups aimed at identification of adverse psychological impacts and psychopathological symptoms in the general population during the pandemics would be of use to governments and healthcare service providers. the methodological analysis as carried out in our study can be further refined by taking into account the fixed and random effects. in particular, the motivation for using fixed effect (fe) and random effect (re) regression model would emanate from identification of such effects explaining variations on measurement items related to output variables, i.e., variables explaining behavioral intention in our case (martin et al., 2010) . however, such methods, for instance, those related to fe (e.g., ordinary regression, uni/multivariate regression models) and re including meta-analysis related (e.g., hunter-schmidt/hedges-vevea) are often considered data hungry methods, wherein some important questions such as how much and what kind of data need to be collected to deploy such models meaningfully and reliably need to be addressed. questions, for instance, whether the data would be pooled in nature or individual respondent based would also aid practitioners in determining the right sampling strategy (martin et al., 2010) . schmidt et al. (2011) in their study discussed comparison of fe and re model for empirical data. they argued that results often vary substantially given the type of model used since fe is often associated with apriori while re takes into account statistical calibration. further, j o u r n a l p r e -p r o o f deploying fe models and generalizing findings are often dichotomous in nature in that fe models can lead to inflated type i error rates and erroneously narrow confidence interval (hedges & vevea, 1998; hunter & schmidt, 2000) . with the advent and phenomenal growth of new technologies based on big data, cloud computing, and blockchain, technology usage is rapidly increasing due to numerous advantages. in healthcare service delivery, technologies concerning professionals, like online appointments, data recording for diagnosis and tracking, etc., are increasingly being adopted. moreover, not only professionals, but patients and their relatives also get influenced by technology. intent of this empirical work was to explore constructs that affect patients' acceptance of technology in healthcare. technology in healthcare has many advantages and at times seems to be only answer to the enormous task of providing universal health coverage. however, for implementation and acceptance of technology in this sector, practitioners and researchers have to take behavioral traits of patients into consideration as well. this empirical study presents an extension to the well-established tam model. primary contribution of this study is integration of behavioral variables (trust and privacy concern) with tam constructs into a parsimonious model that predicts patients' acceptance of technology in healthcare service. this study suggests that trust, privacy concern and perceived utility shape patients attitude towards technology acceptance; while trust and privacy concern directly influence perceived utility. as healthcare service is often characterized by credence of highest degree and different from other services on many accounts, there remains significant scope of unauthorized exploitation of patients' health data. this study suggests that patients' fears about losing privacy has to be dispelled for their acceptance of any newer technology. practitioners and agencies responsible for healthcare need to earn trust of patients before implementing any new technology. the study empirically establishes relationship between trust and privacy concern of patients with their intention of technology acceptance. based on a scenario, the data was collected from primary health centers in india to understand various constructs and to test related hypotheses. based on results and analysis, theoretical and managerial implications are drawn and discussed in detail. one morning you wake up suffering from fever and headache. you had similar problem a few weeks ago and you got all your tests done. you took medicines as prescribed by the doctor. now you feel worried and would like to get in touch with a medical doctor to receive a diagnosis and treatment. you have two options: you may collect all your previous treatment case history, reports, prescriptions, etc., and preferably go to the same doctor from whom you received your treatment on the last time. second option is that, you carry your aadhaar card and go to any health center, which is capable of providing healthcare services by using your aadhaar data. if you choose second option, you have to give your thumb impression to identify yourself. after identification, your all the medical records will be available with the doctor. you don't have to carry any of your previous health records. the doctor, after examining your records and previous diagnosis, will be able to prescribe future course of action. with more certainty, the doctor will be able to decide which tests need to be done. whatever treatment you receive here, everything will be added to your health history so that next time whenever you need health service, you don't have to carry any physical record with you. just by identifying yourself by giving your thumb impression at any health center, all your previous treatment details will be available with stationed doctor there. i am sure that you are aware that your aadhaar is linked with your bank accounts, and other financial subsidies you receive from government. however, such data is safe and secure. at a health center, only your health related data will be accessed. j o u r n a l p r e -p r o o f research commentary-the digital transformation of healthcare: current status and the road ahead estimating nonresponse bias in mail surveys the role of big data analytics in internet of things the theory of planned behavior an extension of the technology acceptance model in an erp implementation environment the australian general public's perceptions of having a personally controlled electronic health record (pcehr) annual report 2016-17. government of national capital territory of delhi, directorate general of health services privacy in practice: professional discourse about information control in healthcare evidence of the effect of trust building technology in electronic market: price premium and buyer behaviour on the evaluation of structure equation models the impact of personal dispositions on information sensitivity, privacy concern and trust in disclosing health information online an alternative interpretation of cognitive dissonance phenomena healthcare: a fertile field for service research the differential performance effects of healthcare information technology adoption a concept of a patientcentered healthcare system based on the virtualized networking and information infrastructure the importance of trust for personalized online advertising consumer trust repair: a critical literature review the benefits of health information technology: a review of the recent literature shows predominantly positive results the utilization of e-government services: citizen trust, innovation and acceptance factors the meaning(s) of trust. a content analysis on the diverse conceptualizations of trust in scholarly research on business relationships systematic review: impact of health information technology on quality, efficiency, and costs of medical care personalization versus privacy: an empirical examination of the online consumer's dilemma social values in health priority setting: a conceptual framework u.s. adoption of computerized physician order entry systems an attitudinal model of technology-based selfservice: moderating effects of consumer traits and situational factors consumer evaluations of new technology-based self-service options: an investigation of alternative models of service quality user acceptance of computer technology: a comparison of two a technology acceptance model for empirical testing new end-user information systems: theory and results. doctoral dissertation, mit perceived usefulness, perceived ease of use, and user acceptance of information technology electronic health records in ambulatory care-a national survey of physicians examining the impact of information technology and patient flow on healthcare performance: a theory of swift and even flow (tsef) perspective it capability for health care delivery: is more better? big data and blockchain supported conceptual model for enhanced healthcare coverage: the indian context internet privacy concerns and social awareness as determinants of intention to transact an extended privacy calculus model for e-commerce transactions an examination of the nature of trust in buyer-seller relationships understanding online b-to-c relationships: an integrated model of privacy concerns, trust, and commitment medrec" prototype for electronic health records and medical research data. white paper belief, attitude, intention and behavior: an introduction to theory and research utility-driven data analytics on uncertain data determinants of long-term orientation in buyer-seller relationships a research agenda for trust in online environments trust and tam in online shopping: an integrated model technology acceptance in health care: an integrative review of predictive factors and intervention programs consumer e-shopping acceptance: antecedents in a technology acceptance model the limits of trust-free systems: a literature review on blockchain technology and trust in the sharing economy retrust: attack-resistant and lightweight trust management for medical sensor networks fixed-and random-effects models in metaanalysis information privacy in online social networks: uses and gratification perspective building consumer trust online the technology acceptance model: its past and its future in health care structural equation modelling: guidelines for determining model fit users' acceptance of electronic patient portals in lebanon trust: the connection link between organizational theory and philosophical ethics human development for everyone fixed effects vs. random effects meta-analysis models: implications for cumulative research knowledge investigating enterprise systems adoption: uncertainty avoidance, intrinsic motivation, and the technology acceptance model privacy concerns on social networking sites: interplay among posting types, content, and audiences use of electronic health records in u.s. hospitals privacy concerns and privacy-protective behavior in synchronous online social interactions an index for factor simplicity organizational and environmental determinants of hospital emr adoption: a national study trust in health information websites: a systematic literature review on the trust a meta-analysis of the technology acceptance model information hangovers in healthcare service systems electronic healthcare: a study of people's readiness and attitude toward performing self-diagnosis understanding consumer privacy: a review and future directions facebook privacy management strategies: a cluster analysis of user privacy behaviors the technology acceptance model: past, present, and future examining individuals' adoption of healthcare wearables devices: an empirical study from privacy calculus perspective hospital technology and nurse staffing management decisions empirical studies on online information privacy concerns: literature review and an integrative framework. communication of the association for information system bsein: a blockchain-based secure mutual authentication with fine-grained access control system for industry 4.0 creating sustainable healthcare system using local health information to promote public health health promotion in the digital era: a critical commentary internet users' information privacy concerns (iuipc): the construct, the scale, and a causal model public standards and patients' control: how to keep electronic medical records accessible but private measuring individual differences in reaction norms in field and experimental studies: a power analysis of random regression models the adoption of hospital information systems the effect of health information technology on quality in u. s. hospitals principles and practice in reporting statistical equation analyses the quality of healthcare delivered to adults in the united states the impact of initial consumer trust on intentions to transact with a web site: a trust building model towards bayesian-based trust management for insider attacks in healthcare software-defined networks new service development competence in retail banking: construct development and measurement validation online health information seeking: the influence of age, information trustworthiness, and search challenges trust and concern in consumers' perceptions of marketing information management practices role of electronic trust in online retailing: a re-examination of the commitment-trust theory evaluation of goodness-of-fit indices for structural equation models applying the technology acceptance model to the introduction of healthcare information systems e-health and wellbeing monitoring using smart healthcare devices: an empirical investigation an updated and streamlined technology readiness index: tri 2.0 technology readiness index (tri): a multiple item scale to measure readiness to embrace new technologies situation awareness, mental workload, and trust in automation: viable, empirically supported cognitive engineering constructs cloud based rural healthcare information system consumer acceptance of electronic commerce: integrating trust and risk with the technology acceptance model fog computing for sustainable smart cities: a survey poverty and access to health care in developing countries antecedents and consequences of consumer privacy concerns: an empirical investigation privacy concerns and consumer willingness to provide personal information an automated picking workstation for healthcare applications the public's trust and information brokers in healthcare, public health and research the quest for privacy in the internet of things the future of healthcare internet of things: a survey of emerging technologies doctors' orders--if they're electronic, do they improve patient satisfaction? a complements/ substitutes perspective a systematic review of the technology acceptance model in health informatics an innovation-diffusion view of implementation of enterprise resource planning (erp) systems and development of a research model a cloud computing solution for patient's data collection in health care institutions not so different after all: a cross-discipline view of trust fixed-versus random-effects models in meta-analysis: model properties and an empirical comparison of differences in results an integrative model of organizational trust: past, present, and future reporting structural equation modeling and confirmatory factor analysis results: a review common method bias in regression models with linear, quadratic, and interaction effects the impact of health information technology bundles on hospital performance: an econometric study information privacy: measuring individuals' concerns about organizational practices healthy bodies and thick wallets: the dual relation between health and economic status why different trust relationships matter for information systems users an empirical examination of the concern for information privacy instrument ehr acceptance among austrian resident doctors validation guidelines for is positivist research. communications of the association for information systems empirical evaluation of the revised technology acceptance model personal health records: definitions, benefits, and strategies for overcoming barriers to adoption research for universal health coverage unique identification authority of india, government of india a theoretical extension of the technology acceptance model: four longitudinal field studies determinants of perceived ease of use: integrating control, intrinsic motivation, and emotion into the technology acceptance model user acceptance of information technology: toward a unified view poverty and health sector inequalities an artificial intelligence driven multi-feature extraction scheme for big data detection big data analytics: understanding its capabilities and potential benefits for healthcare organizations secure authentication scheme for medicine anti-counterfeiting system in iot environment a novel authentication and key agreement scheme for implantable medical devices deployment towards effective trust-based packet filtering in collaborative network environments world health organization. the global burden of disease the adoption of mobile healthcare by hospital's professionals: an integrative perspective examining the formation of individual's privacy concerns: toward an integrative view the personalization privacy paradox: an exploratory study of decision making process for location-aware marketing an empirical study of patients' privacy concerns for health informatics as a service a security and trust framework for virtualized networks and software-defined networking two schemes of privacy-preserving trust evaluation emerging information technologies for enhanced healthcare a chronological review of empirical research on personal information privacy concerns: an analysis of contexts and research constructs security and privacy issues in healthcare systems: towards trusted services big data for supply chain management in the service and manufacturing sectors: challenges, opportunities, and future perspectives factors influencing behaviour intentions to telehealth by chinese elderly: an extended tam model securing m-healthcare social networks: challenges, countermeasures and future directions the impact of privacy concern on user adoption of location-based services key: cord-022103-4zk8i6qb authors: siegel, jane d.; guzman-cottrill, judith a. title: pediatric healthcare epidemiology date: 2017-07-18 journal: principles and practice of pediatric infectious diseases doi: 10.1016/b978-0-323-40181-4.00002-5 sha: doc_id: 22103 cord_uid: 4zk8i6qb nan jane d. siegel the reduction of healthcare-associated infections (hais) is an important component of patient safety programs. five of the 16 hospital national patient safety goals for 2016 of the joint commission (formerly the joint commission on accreditation of healthcare organizations) target prevention of hais. 1 hospitals have learned from high-reliability organizations (e.g., the aviation industry) the importance of adopting changes that include the leadership's commitment to achieving zero patient harm, a fully functional culture of safety throughout the organization, and the widespread deployment of highly effective process improvement tools. 2 involvement of new stakeholders for improving patient safety and outcomes related to hais (e.g., children's hospitals' solutions for patient safety, children's hospital association, individual states' mandatory hai public reporting programs, the centers for medicare and medicaid services, the joint commission) has broadened the arena for hai prevention efforts. knowledge of the complexities of prevention and control of hais in children is critical to many different leaders of children's healthcare facilities. one framework for patient safety in children's hospitals that includes infection prevention and control (ipc) was developed by the ohio children's hospital solutions collaborative and demonstrates the effectiveness of hospitalwide collaboration. 3 as more disciplines in healthcare become engaged in prevention of hais as well as antimicrobial stewardship, it is the responsibility of the healthcare epidemiologist and the ipc staff (infection preventionists, healthcare epidemiologists) to educate the facility leadership on the discipline of ipc. ipc for the pediatric population is a unique discipline that requires understanding of various host factors, sources of infection, routes of transmission, behaviors required for care of infants and children, pathogens and their virulence factors, treatments, preventive therapies, and behavioral theory. although the term nosocomial still applies to infections that are acquired in acute care hospitals, the more general term, healthcare-associated infections (hais), is preferred because much care of high-risk patients, including patients with medical devices (e.g., central venous catheters, ventilators, ventricular shunts, peritoneal dialysis catheters), has shifted to ambulatory settings, rehabilitation or chronic care facilities, and the home; thus, the geographic location of acquisition of the infection often cannot be determined. the principles of transmission of infectious agents in healthcare settings and recommendations for prevention are reviewed in the healthcare and infection control practices advisory committee (hicpac) guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings, 2007 4 and in the management of multidrug resistant organisms in healthcare settings, 2006 document. 5 as new pathogens emerge, epidemiologists will continue to learn more about preventing transmission; therefore, for such pathogens, the most up-to-date guidance posted on the centers for disease control and prevention (cdc) or the world health organization (who) website should be consulted. the experience treating ebola virus disease (evd) in the united states in 2014 is the most recent example of changes in the usual infection prevention paradigm that were required, with emphasis on the hierarchy of controls 6 and donning and doffing of personal protective equipment (ppe) with trained observers. 7 a detailed discussion of hais can be found in chapters 99 and 100. this chapter focuses on the components of an effective pediatric hospital epidemiology program. unique aspects of hais in children are summarized in the following sections. specific risks and pathogens are addressed in several other chapters in this textbook. intensive care units (icus), oncology services, and gastroenterology services caring for patients with short gut syndrome who are dependent on total parenteral nutrition (and lipids) have the highest rates of bacterial and fungal infection associated with central venous catheters. a newer definition of mucosal barrier injury laboratory-confirmed bloodstream infection (mbi-lcbi) currently is used by the national healthcare safety network (nhsn) of the cdc to distinguish bacteremia that represents translocation of gut microorganisms related to mucosal barrier injury in patients with oncologic conditions, hematopoietic stem cell transplantation (hsct), and intestinal failure from bacteremia associated with central venous catheters. 8 hais can result in substantial morbidity and mortality, as well as lifetime physical, neurologic, and developmental disabilities. host (i.e., intrinsic) factors that make children particularly vulnerable to infection include immaturity of the immune system, congenital abnormalities, and congenital or acquired immunodeficiencies. children with congenital anomalies have a high risk of hai if their unusual anatomic features predispose them to contamination of normally sterile sites. moreover, these children require prolonged and repeated hospitalizations, undergo many complex surgical procedures, and have extended exposure to invasive supportive and monitoring equipment. innate deficiencies of the immune system in prematurely born infants, who may be hospitalized for prolonged periods and exposed to intensive monitoring, supportive therapies, and invasive procedures, contribute to the relatively high rates of infection in the neonatal icu (nicu). all components of the immune system are compromised in neonates, and the degree of deficiency is proportional inversely to gestational age (see chapter 9) . the underdeveloped skin of the very low birth weight (<1000 g) infant provides another mode of pathogen entry. populations of immunosuppressed children have expanded with the advent of more intense immunosuppressive therapeutic regimens used for oncologic conditions, hsct, solid-organ transplantation, and rheumatologic conditions and inflammatory bowel disease for which immunosuppressive agents and tumor necrosis factor-α-inhibiting agents (infliximab [remicade] ) and other immune modulators are used. genetic mutations in the genes for the transmembrane conductance regulator (cftr) in children with cystic fibrosis result in thick secretions, chronic endobronchial infections, and gastrointestinal malabsorption. knowledge of the epidemiology of infection of patients with cystic fibrosis and effective methods to prevent patient-to-patient transmission have expanded with the use of newer molecular diagnostic methods, resulting in a 2013 update in the infection prevention and control guideline for cystic fibrosis. 9 fortunately, the population of children with perinatally acquired human immunodeficiency virus (hiv) infection and acquired immunodeficiency syndrome (aids) has decreased dramatically since 1994, but new cases of sexually transmitted hiv infection continue to be diagnosed in teens who receive care in children's hospitals. finally, young infants who have not yet been immunized, or immunosuppressed children who do not respond to vaccines or who lose antibody during disease or treatment (e.g., patients with nephrotic syndrome), have increased susceptibility to vaccine-preventable diseases. the source of many hais is the endogenous flora of the patient. an asymptomatically colonizing pathogen can invade a patient's bloodstream or be transmitted to other patients on the hands of healthcare personnel (hcp) or on shared equipment. other important sources of hais in infants and children include the mother in the case of neonates, toys were implicated in an outbreak of multidrug-resistant pseudomonas aeruginosa in a pediatric oncology unit. 23 although the source of most candida hais is the patient's endogenous flora, horizontal transmission, most likely through hcp hands, has been demonstrated in studies using typing by pulsed gel electrophoresis in the nicu and in a pediatric oncology unit. 24, 25 newer molecular diagnostic methods (e.g., whole genome sequencing) are more sensitive and specific than pulsed gel electrophoresis and have proven to be valuable in identifying outbreaks of a variety of pathogens in both pediatric and adult settings. 26, 27 droplet. infectious respiratory droplets >5 µm in diameter are generated from the respiratory tract by coughing, sneezing, or talking or during such procedures as suctioning, intubation, chest physiotherapy, or pulmonary function testing. transmission of infectious agents by the droplet route requires exposure of mucous membranes to large respiratory droplets within 3 to 6 feet (1 to 2 m) of the infected person. large respiratory droplets do not remain suspended in the air for prolonged periods, and they settle on environmental surfaces. the dynamics of infectious aerosols can be affected by a variety of factors including characteristics of specific strains of bacteria, temperature, humidity, and number of air exchanges in a room. adenovirus, influenza virus, and rhinovirus are transmitted primarily by the droplet route, whereas rsv is transmitted primarily by the contact route. 28 although influenza virus can be transmitted by the airborne route under unusual conditions of reduced air circulation or low absolute humidity, ample evidence indicates that transmission of influenza is prevented by droplet precautions and, in the care of infants, the addition of contact precautions. 29 airborne. droplet nuclei that arise from desiccation of respiratory droplets and are <5 µm in diameter and contain infectious agents remain suspended in the air for prolonged periods and travel long distances on air currents. 4 susceptible persons who have not had face-to-face contact or been in the same room as the source person can inhale such infectious particles. m. tuberculosis, varicella-zoster virus (vzv), and rubeola virus are the agents most frequently transmitted by the airborne route. although transmission of m. tuberculosis by the airborne route can occur rarely from an infant or young child with active tuberculosis, the more frequent source is the adult visitor with active pulmonary tuberculosis that has not yet been diagnosed; thus screening of visiting family members is an important component for control of tuberculosis in pediatric healthcare facilities. 30 some agents (e.g., severe acute respiratory syndrome-coronavirus [sars-cov]) can be transmitted as small-particle aerosols under special circumstances of aerosol-generating procedures (e.g., endotracheal intubation, bronchoscopy); therefore, an n95 or higher respirator is indicated for persons in the same airspace when these procedures are performed, but an airborne infection isolation room (aiir) may not always be required. roy and milton 31 proposed the following classification for aerosol transmission when evaluating routes of sars-cov transmission: 1. obligate: under natural conditions, disease occurs following transmission of the agent only through small-particle aerosols (e.g., tuberculosis). 2. preferential: natural infection results from transmission through multiple routes, but small-particle aerosols are the predominant route (e.g., measles, varicella). 3. opportunistic: agents naturally cause disease through other routes, but under certain environmental conditions they can be transmitted by fine-particle aerosols. this conceptual framework can explain rare occurrences of airborne transmission of agents that are transmitted most frequently by other routes (e.g., smallpox, sars, influenza, noroviruses). concern about airborne transmission of influenza arose during the 2009 influenza a (h1n1) pandemic. however, the conclusion from all published experiences during the pandemic was that droplet transmission is the usual route of transmission, and surgical masks were noninferior to n95 respirators in preventing laboratory-confirmed influenza in hcp. 32, 33 concerns about unknown or possible routes of transmission of agents that can cause severe disease and have no known treatment often result in more extreme prevention strategies. therefore, recommended precautions could change as the epidemiology of emerging agents is defined and these controversial issues are resolved. although no evidence supports airborne transmission of the ebola virus under usual circumstances in the field, the aerosolization of body fluids that contain high titers of ebola virus requires additional protection. 34 invasive monitoring and supportive equipment, blood products, total parenteral nutrition fluids, lipids, infant formula and human milk, hcp, and other contacts, including adult and sibling visitors. maternal infection with neisseria gonorrhoeae, treponema pallidum, hiv, hepatitis b virus, parvovirus b19, mycobacterium tuberculosis, herpes simplex virus, or group b streptococcus, or colonization with multidrug-resistant organisms (mdros), pose substantial threats to the neonate. during perinatal care, procedures such as fetal monitoring using scalp electrodes, fetal transfusion and surgical procedures, umbilical cannulation, and circumcision are potential risk factors for infection. intrinsically contaminated powdered formulas and infant formulas prepared in contaminated blenders or improperly stored or handled have resulted in sporadic and epidemic infections in the nursery (e.g., cronobacter [formerly enterobacter] sakazakii), but such infections have become less frequent since the pathogenesis was defined and contamination reduced. 10 human milk that has been contaminated by maternal flora or by organisms transmitted through breast pumps has caused isolated serious infections and epidemics. the risks of neonatal hepatitis, cytomegalovirus (cmv) infection, and hiv infection from human milk warrant further caution for handling and use of banked breast milk. with increasing numbers of procedures being performed by pediatric interventional radiologists, 11 an understanding of appropriate aseptic technique, as well as prevention and management of infectious complications, by interventional radiologists is important. 12 construction, renovation, demolition, and excavation in and near healthcare facilities are important sources of environmental fungi, (e.g., aspergillus spp., agents of mucormycoses, fusarium spp., scedosporium spp., bipolaris spp.). 13 immunocompromised patients and patients in the pediatric icu (picu) and nicu are at greatest risk for fungal infection, and case fatality rates can be ≥50%, especially if diagnosis and treatment are delayed. practices related to care of infants and young children. several practices must be evaluated with respect to the potentially associated risk of infection. a significant association between reduced levels of nurse staffing and appropriately trained nurses has been demonstrated to increase risk of infection in many studies in both children and adults. 4, 14, 15 theoretical concerns exist that infection risk also will increase in association with the innovative practices of co-bedding of twins and kangaroo care in the nicu because of increased opportunity for skin-to-skin exposure of multiple-gestation infants to each other and to their mothers, respectively. neither the benefits nor the safety of co-bedding multiple-birth infants in the hospital setting has been demonstrated. 16 overall, the infection risk is reduced with kangaroo care, but transmission of tuberculosis and respiratory syncytial virus (rsv) has occurred in kangaroo mother care units in south africa. 17 parents providing kangaroo care should be monitored for the presence of skin infections. antimicrobial selective pressure. exposure to vancomycin and to thirdgeneration cephalosporins contributes substantially to the increase in infections caused by vancomycin-resistant enterococcus (vre) 18 and multidrug-resistant gram-negative bacilli, including extended spectrum β-lactamase (esbl)-producing organisms 19 and carbapenem-resistant enterobacteriaceae 20 (cre) in children. additionally, exposure to thirdgeneration cephalosporins also is a risk factor for the development of invasive candidiasis in low birth weight infants in the nicu. 21 studies of the human microbiome using culture-independent methods have demonstrated the bacterial community diversity on mucosal surfaces and the profound suppressive effect of antimicrobial agents on the population of protective bacteria, firmicutes, thus increasing the risk of colonization and subsequent invasive disease caused by pathogenic bacteria. 22 the principal modes of transmission of infectious agents are direct and indirect contact, droplet, and airborne. 4 contact. most infectious agents are transmitted by the contact route on the hands of hcp or through shared items; many pathogens can be transmitted by more than 1 route. viruses, bacteria, and candida spp. can be transmitted horizontally. toddlers often share waiting rooms, playrooms, toys, books, and other items and therefore have the potential of transmitting pathogens directly and indirectly to one another. contaminated bath part i understanding, controlling, and preventing infectious diseases (nnis), now nhsn icus. hais caused by mdros are associated with increased length of stay, increased morbidity and mortality, and increased cost, in part because of the delay in initiating effective antimicrobial therapy. 43, 44 although the prevalence of specific mdros is lower in pediatric institutions, the same principles of target identification and interventions to control mdros apply in all settings. c. difficile is an important pathogen in children, as it is in adults, especially in children receiving chemotherapy. testing for c. difficile in the first year of life is not advised because of the high asymptomatic colonization rate with toxigenic strains in this age group. candida spp. are the third most frequent pathogens associated with bloodstream infections in us nicus. there is considerable center-tocenter variability in both the incidence of invasive candidiasis and the proportion of candida infections caused by candida non-albicans spp., most of which are resistant to fluconazole. risk factors for candida infections include prolonged length of stay in an icu, use of central venous catheters, intralipids, histamine (h 2 )-blocking agents, and exposure to third-generation cephalosporins. gnb and candida spp. are especially important pathogens for hais in patients with intestinal failure who are receiving total parenteral nutrition, and these organisms can cause repeated episodes of sepsis. the incidence of candida infections had increased in incidence in most picus and nicus during the 1990s, but the rate of c. albicans and non-albicans central line-associated bloodstream infections decreased by 75% in all birth weight categories from 1999 to 2009, 45 likely a result of improved infection control practices, antimicrobial stewardship, and use of fluconazole prophylaxis in the very low birth weight preterm infants. the most recently published clinical practice guidelines of the infectious diseases society of america (idsa) recommend the use of oral or intravenous fluconazole prophylaxis in infants weighing <1000 g at birth in nicus with high rates (>10%) of invasive candidiasis, based on high quality of evidence to support efficacy and safety. 46 additionally, empiric antifungal therapy in preterm infants of ≤1000 g birth weight is associated with improved survival rates without adverse outcomes. 47 the staff members of each nicu first must optimize infection control practices and then assess the remaining risk of candida infections. finally, environmental fungi (e.g., aspergillus, fusarium, scedosporium, bipolaris, agents of mucormycosis) are important sources of infection for severely immunocompromised patients; meticulous attention to the conditions of the internal environment of any facility that provides care for severely immunocompromised patients is required, as well as prevention of possible exposure to construction dust in and around healthcare facilities. 13 with the advent of more effective and less toxic antifungal agents and improved outcomes, it is important to identify promptly the infecting agent by obtaining tissue samples and to determine susceptibility to candidate antifungal agents. prevention remains the mainstay of infection control and requires special considerations in children. the goals of ipc are to prevent the transmission of infectious agents among individual patients or groups of patients, visitors, and hcp who care for them. as new pathogens emerge, new strategies for prevention emerge. the experience treating evd in the us in 2014 and 2015 is the most recent example of changes in the usual infection prevention paradigm that were required, with a renewed emphasis on the 3 tiers of the hierarchy of controls (e.g., engineering, administration, and ppe), donning and doffing of ppe, and use of trained observers. 6, 7 if prevention cannot always be achieved, the strategy of early diagnosis, treatment, and containment is critical. a series of ipc guidelines have been developed and updated at varying intervals by the hicpac/cdc, idsa, society for healthcare epidemiology of america (shea), american academy of pediatrics, association for professionals in infection control and epidemiology, and others to provide evidence-based and rated recommendations for practices that are associated with reduced rates of hais, especially those infections associated with the use of medical devices and surgical procedures. recommended isolation precautions by infectious agent also can be found in the most recent edition of the red book report of the committee on infectious diseases of the american academy of pediatrics. prevention bundles are groups of 3 to 5 evidence-based "best practices" with respect to a process that individually improve care, but when applied together result in substantially greater reduction in infection transmission of microbes between children and hcp is a risk because of the very close contact that occurs during care of infants and young children and is facilitated by overcrowding, understaffing, and too few appropriately trained nurses in pediatric facilities. 4, 14 staffing levels and composition are important components of an effective ipc program. hcp rarely are the source of outbreaks of hais caused by bacteria and fungi, but when they are, certain factors are usually present that increase the risk of transmission (e.g., sinusitis, draining otitis externa, respiratory tract infections, dermatitis, onychomycosis, wearing of artificial nails). [35] [36] [37] persons with direct patient contact who were wearing artificial nails have been implicated in outbreaks of p. aeruginosa and esbl-producing klebsiella pneumoniae in nicus; therefore, the use of artificial nails or extenders is prohibited in persons who have direct contact with high-risk patients. 4 several published studies have shown that infected pediatric hcp, including resident physicians, transmitted bordetella pertussis to other patients and can be the source of other vaccine-preventable infections in healthcare. 38 pathogens associated with hais in children differ from those in adults in that respiratory viruses are more frequently associated with transmission in pediatric healthcare facilities. respiratory viruses (e.g., rsv, parainfluenza, adenovirus, human metapneumovirus) have been implicated in outbreaks in high-risk units. as more respiratory viruses and gastrointestinal pathogens are identified by using highly sensitive molecular methods, epidemiologic studies will be required to define further the risk of transmission in healthcare facilities and the clinical significance of positive antigen detection test results. 40, 41 healthcareassociated outbreaks of varicella, measles, and rotavirus infection now are rare events because of the consistent use of vaccines by children and hcp. the emergence of community-associated mrsa isolates characterized by the unique scc mec type iv element was first observed among infants and children. as rates of colonization with community-associated mrsa at the time of hospital admission increased, so did transmission of community strains, most often usa 300, within the hospital and especially within the nicu, thus making prevention especially challenging. other mdros (e.g., vre, esbls, and cre, especially k. pneumoniae) have emerged as the most challenging healthcare-associated pathogens in both pediatric and adult settings, and otherwise healthy children in the community can be colonized asymptomatically with these mdros. 42 gnb, including esbl and other multidrug-resistant isolates, are more frequent than mrsa and vre in many picus and nicus. patients who are transferred from chronic care facilities may be colonized with mdr gnb at the time of admission to the picu. trends in targeted mdros are tracked in the national nosocomial infections surveillance system 2. oversight of occupational health services related to ipc (e.g., assessment of risk and administration of recommended prophylaxis following exposure to infectious agents, tuberculosis screening, influenza and pertussis vaccination, respiratory protection fit testing, administration of other vaccines as indicated during infectious disease crises such as preexposure smallpox vaccine in 2003 and pandemic influenza a [h1n1] vaccine in 2009) 3. preparedness planning for annual influenza outbreaks, pandemic influenza, sars, middle east respiratory syndrome (mers), bioweapons attacks, and evd 4. adherence monitoring for selected ipc practices 5. oversight of risk assessment and implementation of preventive measures associated with construction, renovation, and other environmental conditions associated with increased infection risk 6. participation in antimicrobial stewardship programs, focusing on prevention of transmission of mdros 7. evaluation of new products and medical devices that could be associated with increased infection risk (e.g., endoscopes, 51 contaminated injectable medications 52 ) and introduction and assessment of performance after implementation of modified products 8. mandatory public reporting of hai rates in states according to enacted legislation 9. increased communication with the public and with local public health departments concerning infection control-related issues 10. participation in local and multicenter reporting and research projects ipc programs must be adequately staffed to perform all the foregoing activities. thus the ratio of 1 infection preventionist to 250 beds that was associated with a 30% reduction in the rates of nosocomial infection in the study on efficacy of nosocomial infection control (senic) performed in the 1970s no longer is sufficient because the complexity of patient populations and responsibilities have increased. many experts recommend that a ratio of 1 infection preventionist to 100 beds is more appropriate for the current workload, but no study has been performed to confirm the effectiveness of that ratio. no information is available on the number of ipc personnel required outside acute care, but it is clear that persons well trained in ipc must be available for all sites where healthcare is delivered. data collected from a member workforce survey conducted in 2015 by the association for professionals in infection control and epidemiology are expected to help determine the optimal number of infection preventionists for different healthcare settings based on the current responsibilities and demographics of infection preventionists. surveillance for hais consists of a systematic method of determining the incidence and distribution of infections acquired by hospitalized patients. the cdc recommends the following: (1) prospective surveillance on a regular basis by trained infection preventionists, using standardized definitions; (2) analysis of infection rates using established epidemiologic and statistical methods (e.g., calculation of rates using appropriate denominators that reflect duration of exposure; use of statistical process control charts for trending rates); (3) regular use of data in decision making; and (4) employment of an effective and trained healthcare epidemiologist who develops ipc strategies and policies and serves as a liaison with the medical community and administration. [53] [54] [55] the cdc has established a set of standard definitions of hais that have been validated and accepted widely with updates posted on the cdc nhsn website. standardization of surveillance methodology has become especially important with the advent of state legislation for mandatory reporting of hai rates to the public. the nhsn now receives, analyzes, and reports data from >17,000 healthcare facilities in the us. a standardized infection ratio (sir) that takes into account differences in risk among healthcare settings, unit types, procedures, and patient populations has been included in summary reports of hai rates since 2009. 56 the centers for medicare and medicaid services and most states use the nhsn data for public reporting of hai rates on their websites. although much effort has been directed toward making these data understandable and useful to consumers, interpretation of rates. adherence to the individual measures within a bundle is readily measured. bundled practices are used most frequently for prevention of device-or procedure-related hais, but they can be applied to prevention of any type of hai. the importance of certain administrative measures for a successful ipc program has been demonstrated. a white paper published by shea summarizes the necessary infrastructure for an effective ipc program in modern times. the paper addresses the expansion of ipc responsibilities from a relatively narrow focus on acute infectious disease events in the acute care hospital, surveillance, and implementation of recommended isolation precautions to a broader set of activities across the continuum of care requiring team work within and beyond individual facilities, usually including large networks. 48 because ipc comprises one component of the institutional culture of safety, it is critical to obtain support from the senior leadership of healthcare organizations to provide necessary fiscal and human resources for a proactive, successful ipc program. critical elements requiring administrative support include access to the following: (1) appropriately trained healthcare epidemiologists and ipc personnel; (2) clinical microbiology laboratory services needed to support infection control outbreak investigations, including ability to perform molecular diagnostic testing; (3) data-mining programs and information technology specialists; (4) multidisciplinary programs to ensure judicious use of antimicrobial agents and control of resistance; (5) development of effective educational information for delivery to hcp, patients, families, and visitors; and (6) local and state health department resources for preparedness. provision of adequate numbers of well-trained infection preventionists and bedside nursing staff is critical for success. an effective ipc program improves safety of patients and hcp and decreases short-term and long-term morbidity, mortality, and healthcare costs. 49 the ipc committee of a facility establishes policies and procedures to prevent or reduce the incidence and costs associated with hais. this committee should be one of the strongest and most accessible committees in the facility; committee composition should be considered carefully and limited to active, authoritative participants who have well-defined committee responsibilities and who represent major groups within the hospital. the chairperson should be a good communicator with expertise in ipc issues, healthcare epidemiology, and clinical pediatric infectious diseases. important functions of the ipc committee are regular review of ipc policies and development of new policies as needed. annual review of all policies is required by the joint commission and can be accomplished optimally by careful review of a few policies each month. with the advent of unannounced inspections, a constant state of readiness is required. the hospital epidemiologist or medical director of the pediatric ipc department usually is a physician with training in pediatric infectious diseases and dedicated expertise in healthcare epidemiology. in multispecialty medical centers where infants and children comprise a small proportion of patients, pediatric infectious disease experts should be consulted for management of pediatric ipc issues and report to the broader ipc leadership. the skillsets, training, and competencies needed for success as a healthcare epidemiologist were summarized in another white paper published by the shea. 50 certification for healthcare epidemiologists has not yet been developed. infection preventionists are specialized professionals with advanced training, and preferably certification, in ipc. although most infection preventionists are registered nurses, other professionals, including microbiologists, medical technologists, pharmacists, and epidemiologists, are successful in this position. pediatric patients should have infection preventionist services provided by professionals with expertise and training in the care of children. in a large, general hospital, at least 1 infection preventionist should be dedicated to ipc services for children. the responsibilities of infection preventionists have expanded greatly and include the following: 1. surveillance and ipc in facilities affiliated with primary acute care hospitals (e.g., ambulatory clinics, day-surgery centers, long-term care facilities, rehabilitation centers, home care) in addition to the primary hospital part i understanding, controlling, and preventing infectious diseases according to 2006 guidelines, if transmission continues after standardized horizontal interventions have been completely implemented. 5 at this time, no formal recommendation has been made to discontinue routine use of contact precautions for patients with asymptomatic colonization with mrsa or vre in an endemic setting; thus each ipc program must determine practice based on local conditions and follow with close auditing and surveillance for potential adverse outcomes. the microbiology laboratory can provide online culture information about individual patients, outbreaks of infection, antibiograms (antibiotic susceptibility patterns of pathogens summarized periodically), and employee infection data. the laboratory also can assist with surveillance cultures and facilitation of molecular typing of isolates during outbreak investigations. rapid diagnostic testing of clinical specimens for identification of respiratory and gastrointestinal tract viruses and b. pertussis is especially important for pediatric facilities. the ipc division and the microbiology laboratory must communicate daily because even requests for cultures or other diagnostic testing from physicians (e.g., m. tuberculosis, neisseria meningitidis, c. difficile) can identify patients early who are infected, are at high risk of infection, or require isolation. if microbiology laboratory work is outsourced, it is important to ensure that the services needed to support effective icp be available, as delineated in a 2013 guideline developed by the idsa and the american society for microbiology. 66 control of unusual infections or outbreaks in the community generally is the responsibility of the local or state public health department; however, the individual facility must be responsible for preventing transmission within that facility. public health agencies can be helpful, particularly in alerting hospitals of community outbreaks so that outpatient and inpatient diagnosis, treatment, necessary isolation, and other preventive measures are implemented promptly to avoid further spread. conversely, designated persons in the hospital must notify public health department personnel of reportable infections to facilitate early diagnosis, treatment, and infection control in the community. benefits of community or regional collaboratives of individual healthcare facilities and local public health departments for prevention of hais, especially those caused by mdros, have been demonstrated, and this collaboration should be encouraged. 4 the rapid increase of mdros is a public health threat. between 20% and 50% of antibiotics prescribed in us hospitals are either inappropriate or unnecessary. 68 in 2014, the president's council of advisors on science and technology submitted a 78-page report to the president on combating antibiotic resistance that raised awareness of antimicrobial resistance to a national level. 69 a national action plan based on this report was released in march 2015, and funding was made available for its implementation. antimicrobial stewardship was defined in a consensus statement by the idsa, shea, and pediatric infectious diseases society in 2012 as "coordinated interventions designed to improve and measure the appropriate use of antibiotic agents by promoting the selection of the optimal antibiotic regimen, including dosing, duration and route of administration." 70 antimicrobial stewardship programs are collaborative partnerships among infection preventionists, healthcare epidemiologists, clinical pharmacists, and microbiologists. hospital administrative support for the infrastructure required for ongoing measurement and reporting of antimicrobial use and other related outcome measures, including feedback to prescribers, is a critical component of a successful antimicrobial stewardship program. an antimicrobial stewardship program can optimize clinical outcomes while decreasing unintended consequences of antimicrobial use, including the emergence of resistant organisms. additionally, use of specific antimicrobial agents can alert the ipc program to the presence of potentially infectious patients (e.g., with pulmonary tuberculosis, mdros). national guidelines exist for developing and implementing an institutional antimicrobial stewardship program, including core components for acute care hospitals and for long-term care facilities. 68, 70 the natinal quality forum and its partners have also developed a playbook that provides additional guidance for implementation of antimicrobial stewardship programs in acute care. the knowledge and skills required for antimicrobial stewardship leaders also have been defined. 50, 71 these data by the public remains difficult, and more research is needed to optimize methods of data display to the public. 57 new york state is the first state to have published an improvement in process and outcomes of central line-associated bloodstream infection rates in nicus following implementation of a public reporting program. 58 although various surveillance methods are used, the basic goals and elements are similar and include using standardized definitions of infection, finding and collecting cases of hais, tabulating data, using appropriate denominators that reflect duration of risk, analyzing and interpreting the data, reporting important deviations from endemic rates (epidemic, outbreaks) to the bedside care providers and to the facility administrators, implementing appropriate control measures, auditing adherence rates for recommended processes, and assessing efficacy of the control measures. medical centers can use different methods of surveillance, as outlined in box 2.1. most experts agree that a combination of methods enhances surveillance and reliability of data, and some combination of clinical chart review and database retrieval is important. whatever data collection systems are used, validation is required. administrative databases created for the purposes of billing should not be used as the sole source to identify hais because of overestimates and underestimates that result from inaccurate coding of hais. 59 use of software designed specifically for ipc data entry and analysis facilitates real-time tracking of trends and timely intervention when clusters are identified. the ipc team should participate in the development and update of electronic medical record systems for a healthcare organization, to ensure that surveillance needs will be met. controversy has surrounded the role of obtaining active surveillance cultures from all patients admitted to an acute care hospital, especially to an icu, to detect asymptomatic colonization with mrsa or vre and then placing those persons on contact precautions in an endemic setting, a practice referred to as a vertical approach. 60, 61 more recently published experiences demonstrate the benefits of a horizontal approach to reduce the risk of transmission of a broader variety of pathogens, 61 and a framework for a less restrictive approach has been published. 62 contributing factors to the benefits of the horizontal approach include the following: (1) widespread implementation of bundled prevention practices, including limiting use of unnecessary medical devices; (2) improved understanding and more consistent implementation of standard precautions, especially hand hygiene; (3) establishment of the safety and efficacy of universal decolonization using chlorhexidine bathing in icus 63, 64 and nicus for infants weighing >1000 g at birth 65 ; (4) improving environmental cleaning; and (5) identified the following potential infection control breaches: (1) use of multidose vials for heparin or saline administration; (2) poor compliance with hand hygiene before and after patient contacts or after touching a possibly contaminated surface; (3) failure to change gloves between patient contacts or after contact with a potentially contaminated surface; (4) failure to disinfect environmental surfaces adequately; (5) unsafe injection practices; (6) failure to disinfect shared equipment between patient uses; (7) lack of a separate area for medication preparation; and (8) failure to have clean and dirty utility rooms clearly separated. 78 two additions were made to standard precautions in 2007: (1) respiratory hygiene or cough etiquette for source containment by people with signs and symptoms of respiratory tract infection and (2) use of a mask by personnel inserting an epidural anesthesia needle or performing a myelogram when prolonged exposure of the puncture site is likely. both components have a strong evidence base. implementation of standard precautions requires the availability of ppe in proximity to all patient care areas. hcp with exudative lesions or weeping dermatitis must avoid direct patient care and handling of patient care equipment. persons having direct patient contact should be able to anticipate exposure incurring risks and steps to take if a highrisk exposure occurs. exposures of concern are as follows: exposures to blood or other potentially infectious material defined as an injury with a contaminated sharp object (e.g., needlestick, scalpel cut); a spill or splash of blood or other potentially infectious material onto nonintact skin (e.g., cuts, hangnails, dermatitis, abrasions, chapped skin) or onto a mucous membrane (e.g., mouth, nose, eye); or blood exposure covering a large area of normal skin. patient-related duties that do not constitute high-risk exposures include handling food trays or furniture, pushing wheelchairs or stretchers, using restrooms or telephones, having personal contact with patients (e.g., giving information, touching intact skin, bathing, giving a back rub, shaking hands), or performing clerical or administrative functions for a patient. if hands or other skin surfaces are exposed to blood or other potentially infectious material, the area should be washed immediately with soap and water for at least 10 seconds and rinsed with running water for at least 10 seconds. for an eye, nose, or mouth splash with blood or body fluids, the area should be irrigated immediately with a large volume of water. if a skin cut, puncture, or lesion is exposed to blood or other potentially infectious material, the area should be washed immediately with soap and water for at least 10 seconds and rinsed with 70% isopropyl alcohol. any exposure incident should be reported immediately to the occupational health department to determine whether blood samples are required from the source patient and the exposed person and if immediate prophylaxis is indicated. all hcp should know where to find the exposure control plan specific to each place of employment, whom to contact, where to go, and what to do if inadvertently exposed to blood or body fluids. important resources include the occupational health department, the emergency department, and the infection control or hospital epidemiology division. the most important recommendation in any accidental exposure is to seek advice and intervention immediately because the efficacy of recommended prophylactic regimens is improved with shorter intervals after exposure, such as for hepatitis b immune globulin administration after exposure to hepatitis b virus or for antiretroviral therapy after percutaneous exposure to hiv. chemoprophylaxis following exposure to hiv-infected material is most effective if it is initiated as soon as possible, but within hours of exposure. 79 the current guidelines recommend using ≥3 drugs for postexposure prophylaxis of hiv independent of the severity of exposure. updates are posted on the cdc website as they are developed. reporting a work-related exposure is required for subsequent medical care and workers' compensation. transmission-based precautions are designed for patients with documented or suspected infection with pathogens for which additional precautions beyond standard precautions are needed to prevent transmission. the 3 categories of transmission-based precautions are contact precautions, droplet precautions, and airborne precautions, and they are based on the likely routes of transmission of specific infectious agents. transmission-based precautions are combined for infectious agents that have more than 1 route of transmission. when used singly or in the effectiveness of antimicrobial stewardship programs in achieving improved patient outcomes is evident in pediatric acute care hospitals, 72, 73 including the nicu, 74, 75 in ambulatory settings, and in long-term care facilities. the area of antimicrobial stewardship, however, requires additional research to establish optimal methods in various pediatric specialty populations. one practice from the cdc get smart program that can be implemented by each prescriber in most settings is the antibiotic "time out" that consists of reviewing patient data at 48 to 72 hours of treatment to determine which of the following is indicated: (1) continue antibiotic treatment; (2) change to a narrower-spectrum agent; (3) change from a parenteral to an oral agent; or (4) shorten or conclude therapy. 68 isolation of patients with potentially transmissible infectious diseases is a strategy proven to prevent transmission of infectious agents in healthcare settings. many published studies, performed in both adult and pediatric settings, provide a strong evidence base for most recommendations for isolation precautions and for limiting outbreaks. however, controversies exist concerning the most clinically and cost-effective measures for preventing certain hais, especially those associated with mdros. as discussed earlier in the section on surveillance, a call has gone out to reconsider recommendations for isolation of patients who are asymptomatically colonized with mrsa or vre, but no definite recommendation has been made by the hicpac/cdc, shea, or association for professionals in infection control and epidemiology. since 1970, the guidelines for isolation developed by cdc have responded to the needs of the evolving us healthcare systems. for example, universal precautions became a required standard in response to the hiv epidemic that emerged in the 1980s and the need to prevent acquisition of bloodborne pathogens (e.g., hiv, hepatitis b and c viruses) by hcp through skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials from persons not known to be or suspected of being infected. universal precautions were modified and have been known as standard precautions since publication of the 1996 guideline for isolation. the federal needlestick safety and prevention act, signed into law in november 2000, authorized the occupational safety and health administration's revision of its bloodborne pathogens standard more explicitly to require the use of safety-engineered sharp devices. 76 evidence and recommendations are provided for the prevention of transmission of mdros such as mrsa, vre, visa, vrsa, and gnb. 4, 5 the components of a protective environment for prevention of environmental fungal infections in hsct recipients are summarized. 4 finally, evidence-based, rated recommendations for administrative measures that are necessary for effective prevention of infection in healthcare settings are provided. the most recent guideline for isolation precautions published in 2007 4 reaffirms standard precautions, a combination of universal precautions and body substance isolation, as the foundation of transmission prevention measures. critical thinking is required for hcp to recognize the importance of body fluids, excretions, and secretions in the transmission of infectious pathogens and take appropriate protective precautions by using ppe (e.g., masks, gowns, gloves, face shields, or goggles) and safety devices when exposure is likely even if an infection is not suspected or known. in addition, these updated guidelines provide recommendations for standard precautions in all settings in which healthcare is delivered (acute care hospitals, ambulatory surgical and medical centers, longterm care facilities, and home health agencies). the components of standard precautions are summarized in table 2 instruct symptomatic persons to cover the mouth or nose when sneezing or coughing; use tissues and dispose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory secretions; wear a surgical mask if tolerated or maintain spatial separation, >1-2 m (3-6 feet) if possible a during aerosol-generating procedures on patients with suspected or proven infections transmitted by aerosols (e.g., severe acute respiratory syndrome), wear a fit-tested n95 or higher respirator in addition to gloves, gown, and face and eye protection. although targeted contact precautions and universal gowning and gloving are effective for preventing transmission of infectious agents, potential adverse effects in patients placed on contact precautions have been described (e.g., depression, fewer visits from the healthcare team, increased rates of hypoglycemia or hyperglycemia, increased falls). 80 additionally, adherence to contact precautions decreases as the number of patients on contact precautions increases. 81 finally, a simulation study demonstrated contamination of hcp skin and clothing during doffing of gowns and gloves 82 ; this study effectively demonstrated the ppe lessons learned during the sars and evd experiences. evidence supports the importance of applying contact precautions only when indicated, obtaining training on the use of ppe, having effective ppe readily available, and practicing consistent and precise use of ppe. 83 table 2.2 lists the 3 categories of isolation based on routes of transmission and their necessary components. table 2 .3 lists precautions by syndromes, to be used when a patient has an infectious disease and the agent is not yet identified. for infectious agents that are more likely to be transmitted by the droplet route (e.g., pandemic influenza), droplet precautions (with use of surgical mask) are appropriate; however, during an aerosol-generating procedure, n95 or higher respirators are indicated. 84 contaminated environmental surfaces and noncritical medical items have been implicated in transmission of several infectious agents, including vre, c. difficile, acinetobacter spp., mrsa, and rsv in healthcare settings. 4, 85, 86 pathogens on surfaces are transferred to the hands of hcp and are then transferred to patients or items to be shared. occupying a room previously occupied by a patient with a key pathogen is a risk factor for acquiring that pathogen during a hospital stay. most often, the failure to follow recommended procedures for cleaning and disinfection contributes more than does the specific pathogen to the environmental reservoir during outbreaks. education of environmental services personnel combined with direct observation and feedback was associated with a persistent decrease in vre acquisition in a medical icu. use of a standardized cleaning checklist and implementation of monitoring for adherence to recommended environmental cleaning practices are important determinants of success. visual markers (e.g., invisible fluorescein powder) and adenosine triphosphate bioluminescence technologies are self-disinfecting surfaces can be created by altering the structure of the surface material or by incorporating a material that has antimicrobial activity. [85] [86] [87] copper has antimicrobial activity against a wide range of organisms including bacteria and fungi. thus, incorporating copper into high-touch surfaces such as toilet seats, bed rails, door handles, or countertops is a novel infection prevention strategy that has been shown to reduce bacterial colony counts compared with control surfaces in healthcare settings. 89 however, no recommendation for routine use has yet been made. disinfection and sterilization as they relate to ipc have been reviewed, 90 and the hicpac/cdc developed comprehensive guidelines in 2008. 91 cleaning is the removal of all foreign material from surfaces and objects. this process is accomplished using soap and enzymatic products. failure to remove all organic material from items before disinfection and sterilization reduces the effectiveness of these processes. disinfection is a process that eliminates all forms of microbial life except the endospore. disinfection usually requires liquid chemicals. disinfection of an inanimate surface or object is affected adversely by the following: the presence of organic matter; a high level of microbial contamination; use of too dilute germicide; inadequate disinfection time; an object that also useful for monitoring effective environmental cleaning and providing immediate feedback to workers. 87 a program of environmental cleaning should be developed collaboratively by the ipc and environmental services departments. certain infectious agents (e.g., rotavirus, noroviruses, c. difficile) can be resistant to some routinely used hospital disinfectants; thus when ongoing transmission occurs despite appropriate cleaning procedures, a 1 : 10 dilution of 5.25% sodium hypochlorite (household bleach) or other special disinfectants are indicated. "no-touch" automated room decontamination technologies have been developed and added to room turnover procedures in some facilities. ultraviolet light irradiation and hydrogen peroxide vapor systems have been shown to reduce surface contamination with common pathogens and decrease the risk of acquiring hais caused by those pathogens when these systems are added to a terminal cleaning regimen. [85] [86] [87] at specific wavelengths, ultraviolet light breaks the molecular bonds in dna, thus destroying the organisms. ultraviolet technology also has been considered as a method of disinfecting ppe, as a risk mitigation strategy for hcp caring for patients with evd. 88 these technologies supplement, but do not replace, standard cleaning and disinfection because surfaces must be physically cleaned of particulate matter and debris. other disadvantages of these systems are that they cannot be used when people are in the rooms, room turnover is delayed, and the systems are expensive to purchase. no recommendations have been made for routine use or specific indications because research on antimicrobial effectiveness, cost effectiveness, and feasibility of these systems is ongoing. patients with the syndromes or conditions listed may have atypical signs or symptoms (e.g., neonates and adults with pertussis may not have paroxysmal or severe cough). the clinician's index of suspicion should be guided by the prevalence of specific conditions in the community, as well as clinical judgment. c the organisms listed under the column "potential pathogens" are not intended to represent the complete, or even most likely, diagnoses, but rather possible etiologic agents that require additional precautions beyond standard precautions until they can be excluded. influenza season. several children's hospitals provide influenza vaccine or tetanus, diphtheria, and acellular pertussis (tdap) vaccine, or both, to household contacts at no charge, thereby supporting the cocooning strategy endorsed by the advisory committee on immunization practices and the american academy of pediatrics. 96 for patients requiring contact precautions, the use of ppe by visitors is determined by the nature of the interaction with the patient and the likelihood that the visitor will frequent common areas on the patient's unit or interact with other patients and their families. it is important to distinguish parents or guardians from nonhousehold visitors when determining whether the visitor should wear ppe. the risk-benefit decision should weigh not only the specific pathogen in question, but also the effect of parental or guardian ppe on breastfeeding, bonding, and family participation in the child's medical care. for family members who are rooming in with children who have prolonged hospitalizations, restriction of visitation to other patients is emphasized. a shea expert guidance document has been published to summarize the principles to follow to prevent transmission of infectious agents by visitors to patients because few data are available to inform evidence-based recommendations. 97 although most pediatricians encourage visits by siblings in inpatient areas, the medical risk must not outweigh the psychosocial benefit. families favorably regard sibling visitation, and no evidence indicates increased bacterial colonization or subsequent bacterial infection in the neonate or older child who has been visited by siblings. strict guidelines for sibling visitation should be established and enforced in an effort to maximize visitation opportunities and minimize risks of transmission of infectious agents, most frequently viruses. the following recommendations regarding visitation can guide policy development: 1. sibling visitation is encouraged in the well-child nursery and nicu, as well as in areas for care of older children. 2. before visitation, parents should be interviewed by a trained staff nurse concerning the current health status of the sibling. siblings should not be allowed to visit if they are delinquent in recommended vaccines, have fever or symptoms of an acute illness, or are within the incubation period following exposure to a known infectious disease. after the interview, the physician or nurse should place a written consent for sibling visitation in the patient's permanent record and a name tag indicating that the sibling has been approved for visitation for that day. 3. asymptomatic siblings who recently were exposed to varicella but who previously were immunized can be assumed to be immune. 4. the visiting sibling should visit only his or her sibling and not be allowed in playrooms with groups of patients. 5. visitation should be limited to periods of time that ensure adequate screening, observation, and monitoring of visitors by medical and nursing staff members. 6. children should perform hand hygiene before and after contact with the patient or upon entry and departure from the patient's room. 7. during the entire visit, sibling activity should be supervised by parents or another responsible adult. animal-assisted therapy can be of substantial clinical benefit to the child hospitalized for prolonged periods; therefore it is important for healthcare facilities to provide guidance for safe visitation. many zoonoses and infections are attributable to animal exposure (see chapter 89) . most infections result from inoculation of animal flora through a bite or scratch or self-inoculation after contact with the animal, the animal's secretions or excretions, or contaminated environment. although few data support a true evidence-based guideline for animal visitation (including personal pets) in healthcare facilities, updated expert guidance is provided in the shea expert guidance on animals in healthcare facilities: recommendations to minimize potential risk, which includes a review of the literature related to animal-assisted activities. 98 prudent visitation policies should limit visitation to animals that: (1) are domesticated; (2) do not require a water environment; (3) do not bite or scratch; (4) can be brought to the hospital in a carrier or easily walked on a leash; (5) are trained to defecate and urinate outside or in appropriate litter boxes; (6) can be bathed before visitation; and (7) are known to be free of respiratory, dermatologic, and gastrointestinal tract disease. despite the established risk of salmonellosis can harbor microbes in protected cracks, crevices, and hinges; and ph and temperature. sterilization is the eradication of all forms of microbial life, including fungal and bacterial spores. sterilization is achieved by physical and chemical processes such as steam under pressure, dry heat, ethylene oxide, and liquid chemicals. the spaulding classification of patient care equipment as critical, semicritical, and noncritical items with regard to sterilization and disinfection is used by the cdc. critical items require sterilization because they enter sterile body tissues and carry a high risk of causing infection if they are contaminated; semicritical items require disinfection because they may contact mucous membranes and nonintact skin; and noncritical items require routine cleaning because they come in contact only with intact skin. if noncritical items used on patients requiring transmission-based precautions, especially contact precautions, must be shared, these items should be disinfected between uses. guidelines for specific objects and specific disinfectants are published and updated by the cdc. multiple published reports and manufacturers similarly recommend the use and reuse of objects with appropriate sterilization, disinfection, or cleaning recommendations. recommendations in guidelines for reprocessing endoscopes to avoid contamination focus on training of personnel, meticulous manual cleaning, high-level disinfection followed by rinsing and air-drying, and proper storage. 92 however, outbreaks of mdr gnb infections associated with exposure to duodenoscopes used for retrograde cholangiopancreatography that have been reprocessed according to recommendations suggest a need for new endoscope reprocessing technologies. 51, 93 these endoscopes have a complex design with long, narrow channels, crevices that are difficult to access with a cleaning brush, right-angle turns, and heavy microbial contamination following procedures. until new methods are developed, meticulous adherence to recommended processes with enhancements should be followed. medical devices that are designed for single use (e.g., specialized catheters, electrodes, biopsy needles) must be reprocessed by third parties or hospitals according to the guidance issued by the food and drug administration (fda) in august, 2000 with amendments in september, 2006; such reprocessors are considered and regulated as "manufacturers." available data show that single-use devices reprocessed according to the fda regulatory requirements are as safe and effective as new devices. deficiencies in disinfection and sterilization leading to infection have resulted either from failure to adhere to scientifically based guidelines or failures in the disinfection or sterilization processes. when such failures are discovered, an investigation must be completed, including notification of patients and, in some cases, testing for infectious agents. a guidance document for risk assessment and communication to patients in such situations is published. 94 healthcare facility waste is all biologic or nonbiologic waste that is discarded and not intended for further use. medical waste is material generated as a result of use with a patient, such as for diagnosis, immunization, or treatment, and it includes soiled dressings and intravenous tubing. infectious waste is that portion of medical waste that potentially could transmit an infectious disease. microbiologic waste, pathologic waste, contaminated animal carcasses, blood, and sharps are all examples of infectious waste. methods of effective disposal of infectious waste include incineration, steam sterilization, drainage to a sanitary sewer, mechanical disinfection, chemical disinfection, and microwave treatment. state regulations guide the treatment and disposal of regulated medical waste. recommendations are available for developing and maintaining a program within a facility for safe management of medical waste. 95 special visitation policies are required in pediatric units, especially the high-risk units, because acquisition of a seemingly innocuous viral infection in neonates and in children with underlying diseases can result in unnecessary evaluations and empiric therapies for suspected septicemia as well as serious, life-threatening disease. all visitors with signs or symptoms of respiratory or gastrointestinal tract infection should be restricted from visiting patients in healthcare facilities. increased restrictions may be required during a community outbreak (e.g., sars, pandemic influenza, enterovirus d68). during respiratory virus season, the number of visitors can be limited and the age restriction increased. it is preferred for all visitors to be immunized against influenza during part i understanding, controlling, and preventing infectious diseases respiratory viruses, norovirus, and tuberculosis. important preventive procedures for hcp with infants at home or who are pregnant are as follows: (1) consistent training and observance of standard precautions, transmission-based precautions, and especially hand hygiene according to published recommendations; (2) annual influenza and 1-time tdap immunization (unless pregnant, when a tdap immunization during each pregnancy is recommended); (3) routine tuberculosis screening; (4) assurance of immunity or immunization against poliomyelitis, measles, mumps, hepatitis b, and rubella; (5) early medical evaluation for acute infectious illnesses; (6) routine, on-time immunization of infants; and (7) prompt initiation of prescribed prophylaxis or therapy following exposure or development of certain infections. hcp who are, could be, or anticipate becoming pregnant should feel comfortable working in the healthcare workplace. in fact, with standard precautions and appropriate adherence to environmental cleaning and isolation precautions, vigilant hcp can be at less risk than a preschool teacher, childcare provider, or mother of children with many playmates in the home. pathogens of potential concern to pregnant hcp include cytomegalovirus, hepatitis b virus, influenza, measles, mumps, parvovirus b19, rubella, vzv, m. tuberculosis, and, since 2015, zika virus. the causal association between zika virus and microcephaly and other neurodevelopmental abnormalities 109 has led to recommended precautions. although zika virus is more frequently acquired outside of healthcare, pregnant hcp are advised to follow safe injection practices for prevention of exposure to infectious blood. 4 pregnancy is an indication for influenza vaccine to prevent the increased risk of serious disease and hospitalization that occurs in women who develop influenza in the second or third trimester of pregnancy. in 2011, the cdc recommended universal immunization with tdap (if previously not immunized with tdap) for pregnant women after 20 weeks of gestation, and since 2012, the cdc recommends a dose of tdap with each pregnancy. 110 pregnant workers should assume that all patients potentially are infected with cytomegalovirus and other "silent" pathogens and should use hand hygiene and gloves when handling body fluids, secretions, and excretions. table 2 .4 summarizes information about infectious agents that are relevant to the pregnant woman working in healthcare. chapters on each agent may be consulted for more specific information. the risk of hais in pediatric ambulatory settings is substantial, and it usually is associated with lack of adherence to routine ipc practices and procedures, especially disinfection, sterilization, and hand hygiene. respiratory viral agents and m. tuberculosis are noteworthy pathogens transmitted in ambulatory settings. transmission of rsv in an hsct outpatient clinic has been demonstrated using molecular techniques. 111 crowded waiting rooms, toys, furniture, lack of isolation of children, unwell children, contaminated hands, contaminated secretions, and susceptible hcp are only some of the factors that result in sporadic and epidemic illness in outpatient settings. the association of communityassociated mrsa in hcp working in an outpatient hiv clinic with environmental community-associated mrsa contamination of that clinic indicates the potential for transmission in this setting. 112 patientto-patient transmission of burkholderia species and p. aeruginosa in outpatient clinics for patients with cystic fibrosis has been confirmed and prevented by implementing recommended ipc methods. 9 ipc guidelines and policies for pediatric outpatient settings, including office practices, were published by the american academy of pediatrics in 2007, 113 reaffirmed in 2015, and are updated currently. prevention strategies include definition of policies, education, and strict adherence to guidelines. in pediatrics, among the most important interventions are separation of children with respiratory tract illnesses from well children and consistent implementation of respiratory etiquette or cough hygiene. a guideline for ipc for outpatient settings with a checklist and a guideline for outpatient oncology settings can be found on the cdc website. 114 principles and recommendations for safe living after hsct 115 and for patients with cystic fibrosis 9 are valuable contributions to management of infectious risks for specific populations in the ambulatory setting. a guideline based on data and expert consensus opinion for ipc in residential facilities for associated with reptiles (e.g., turtles, iguanas), many reports of outbreaks of invasive disease associated with reptiles continue to be published 99 ; reptiles should be excluded from pet visitation programs, and families should be advised not to have pet reptiles in the home with young infants or immunocompromised persons. exotic animals that are imported should be excluded because of unpredictable behavior and the potential for transmission of unusual pathogens (e.g., monkeypox in the us in 2003). 100, 101 visitation should be limited to short periods and confined to designated areas. visiting pets must have a certificate of immunization from a licensed veterinarian. children should observe hand hygiene after contact with animals. most pediatric facilities restrict pet interaction with severely immunosuppressed patients and patients in icus. occupational health and student health collaboration with the ipc department of a healthcare facility is required by the occupational safety and health administration. hcp are at increased risk of infection in hospitals caring for children because (1) children have a high incidence of infectious diseases, (2) personnel can be susceptible to many pediatric pathogens, (3) pediatric care requires close contact, (4) children lack good personal hygiene, (5) infected children can be asymptomatic, and (6) hcp are exposed to multiple family members who also may be infected. the occupational health department is an educational resource for information on infectious pathogens in the healthcare workplace. in concert with the ipc service, occupational health provides preemployment education and respirator fit testing and annual retraining for all employees regarding routine health maintenance, available recommended and required vaccines, standard and transmission-based precautions, and exposure control plans. screening for tuberculosis at regular intervals, as determined by the facility's risk assessment, can use either tuberculin skin testing or interferon-γ release assays. 102 with new pathogens being isolated, new diseases and their transmission described, and new prophylactic regimens and treatment available, it is mandatory that personnel have an up-to-date working knowledge of ipc and know where and what services, equipment, and therapies are available for hcp. all hcp should be screened by history or serologic testing, or both, to document their immune status to specific agents, and immunization should be provided for the following for all employees who are nonimmune and who do not have contraindications to receiving the vaccine: diphtheria toxoid, hepatitis b virus, influenza (yearly), mumps, poliomyelitis, rubella, rubeola, varicella, and tdap. the 2006 advisory committee on immunization practices recommendation to administer a single dose of tdap to certain hcp was amended in 2011 to have no restriction based on age or time interval since the last td dose. providing vaccines at no cost to hcp increases acceptance. influenza vaccine coverage among hcp has increased over time to 77% overall for the 2014 to 2015 influenza season, with the highest coverage rate of 90% in hcp working in hospitals and the lowest rate of 64% in long-term care settings. 103 although mandatory influenza vaccination programs for all employees in healthcare facilities are endorsed by many professional societies, 104,105 some facilities have had success using novel strategies that include incentives, without a mandate. 106 publications from several large institutions, including children's hospitals, indicate that mandatory programs with only medical and religious exemptions are well received, and only rare employees are terminated for failure to be vaccinated. 107, 108 special concerns of healthcare personnel hcp who have common underlying medical conditions should be able to obtain general information on wellness and screening when needed from the occupational health service. hcp with direct patient contact who have infants <1 year of age at home often are concerned about acquiring infectious agents from patients and transmitting them to their susceptible children. an immune healthcare worker who is exposed to vzv does not become a silent "carrier" of vzv. however, pathogens to which the healthcare worker is partially immune or nonimmune can cause a severe, mild, or asymptomatic infection in the employee that can be transmitted to family members. examples include influenza, pertussis, rsv and other pediatric patients and their families provides practical guidance for settings where high-risk patients live with their families for varying periods of time. 116 ipc challenges now are being addressed in long-term care facilities for children. 117 more data are needed to determine the most effective and least restrictive practices. all references are available online at www.expertconsult.com. ohio children's hospitals' solutions for patient safety: a framework for pediatric patient safety improvement mucosal barrier injury laboratoryconfirmed bloodstream infection: results from a field test of a new national healthcare safety network definition prevention and management of infectious complications of percutaneous interventions review of fungal outbreaks and infection prevention in healthcare settings during construction and renovation nurse staffing and nicu infection rates carbapenem-resistant enterobacteriaceae in pediatric patients: epidemiology and risk factors the effects of antibiotics on the microbiome throughout development and alternative approaches for therapeutic modulation necessary infrastructure of infection prevention and healthcare epidemiology programs: a review guidance for infection prevention and healthcare epidemiology programs: healthcare epidemiologist skills and competencies approaches for preventing healthcareassociated infections: go long or go wide? disinfection and sterilization: an overview references 1. the joint commission. national patient safety goals high-reliability health care: getting there from here ohio children's hospitals' solutions for patient safety: a framework for pediatric patient safety improvement guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings management of multidrug-resistant organisms in healthcare settings addressing infection prevention and control in the first u.s. community hospital to care for patients with ebola virus disease: context for national recommendations and future strategies ebola virus disease: preparedness and lessons learned from two biocontainment units mucosal barrier injury laboratoryconfirmed bloodstream infection: results from a field test of a new national healthcare safety network definition and the guideline writing committee. infection prevention and control guideline for cystic fibrosis: 2013 update enterobacter sakazakii: an emerging pathogen in powdered infant formula infection in pediatric interventional radiology prevention and management of infectious complications of percutaneous interventions review of fungal outbreaks and infection prevention in healthcare settings during construction and renovation the effect of nurse staffing on clinical outcomes of children in hospital: a systematic review nurse staffing and nicu infection rates co-bedding in neonatal nursery for promoting growth and neurodevelopment in stable preterm twins committee on fetus and newborn. skin to skin care for term and pre-term infants in the neonatal icu risk factors and outcomes for vancomycinresistant enterococcus bloodstream infections in children risk factors for and outcomes of bloodstream infection caused by extended-spectrum beta-lactamase-producing escherichia coli and klebsiella species in children carbapenem-resistant enterobacteriaceae in pediatric patients: epidemiology and risk factors the association of third-generation cephalosporin use and invasive candidiasis in extremely low birth-weight infants the effects of antibiotics on the microbiome throughout development and alternative approaches for therapeutic modulation multiresistant pseudomonas aeruginosa outbreak in a pediatric oncology ward related to bath toys molecular epidemiology of candida parapsilosis sepsis from outbreak investigations in neonatal intensive care units outbreak of fungemia due candida parapsilosis in a pediatric oncology unit single molecule sequencing to track plasmid diversity of hospital-associated carbapenemase-producing enterobacteriaceae whole genome sequencing in real-time investigation and management of a pseudomonas aeruginosa outbreak on a neonatal intensive care unit modes of transmission of respiratory syncytial virus transmission of influenza a in human beings tuberculosis among adult visitors of children with suspected tuberculosis and employees at a children's hospital airborne transmission of communicable infection: the elusive pathway control of influenza in healthcare settings: early lessons from the 2009 pandemic surgical masks for protection of healthcare personnel against pandemic novel swine-origin influenza a (h1n1)-2009: results from an observational study protecting healthcare personnel from acquiring ebola virus disease how often do asymptomatic healthcare workers cause methicillin-resistant staphylococcus aureus outbreaks? a systematic evaluation outbreak of extended-spectrum betalactamase-producing klebsiella pneumoniae in a neonatal intensive care unit linked to artificial nails pseudomonas aeruginosa outbreaks in the neonatal intensive care unit: a systematic review of risk factors and environmental sources preventing the spread of pertussis in pediatric healthcare settings healthcare providers as sources of vaccine-preventable diseases respiratory viral detection in children and adults: comparing asymptomatic controls and patients with community-acquired pneumonia multicenter evaluation of the biofire filmarray gastrointestinal panel for etiologic diagnosis of infectious gastroenteritis the prevalence and molecular epidemiology of multidrug-resistant enterobacteriaceae colonization in a pediatric intensive care unit recognition and prevention of multidrug-resistant gram-negative bacteria in the intensive care unit epidemiology and clinical outcomes of multidrug-resistant gram-negative bloodstream infections in a european tertiary pediatric hospital during a 12-month period trends in candida central line-associated bloodstream infections among nicus clinical practice guideline for the management of candidiasis: 2016 update by the infectious diseases society of america empiric antifungal therapy and outcomes in extremely-low-birth-weight infants with invasive candidiasis necessary infrastructure of infection prevention and healthcare epidemiology programs: a review patient safety: infection control: a problem for patient safety guidance for infection prevention and healthcare epidemiology programs: healthcare epidemiologist skills and competencies new delhi metallo-β-lactamase-producing carbapenem-resistant escherichia coli associated with exposure to duodenoscopes fungal infections associated with contaminated methylprednisolone injections the scientific basis for using surveillance and risk factor data to reduce nosocomial infection rates feeding back surveillance data to prevent hospital-acquired infections statistical process control as a tool for research and healthcare improvement national healthcare safety network report, data summary for 2013, device-associated module lack of patient understanding of hospitalacquired infection data published on the centers for medicare and medicaid services hospital compare website compliance with prevention practices and their association with central line-associated blood stream infections in neonantal intensive care units guidance on public reporting of healthcareassociated infections: recommendations of the healthcare infection control practices advisory committee reconsidering contact precautions for endemic methicillin-resistant staphylococcus aureus and vancomycin-resistant enterococcus approaches for preventing healthcareassociated infections: go long or go wide? control of drug-resistant pathogens in endemic settings: contact precautions, controversies, and a proposal for a less restrictive alternative targeted versus universal decolonization to prevent icu infection interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in intensive care units: an interrupted time series study and cluster randomised trial chlorhexidine bathing in a tertiary care neonatal intensive care unit: impact on central line-associated bloodstream infections a guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the infectious diseases society of america (idsa) and the modeling spread of kpc-producing bacteria in long-term acute care hospitals in the chicago region core elements of hospital antibiotic stewardship programs report to the president on combating antibiotic resistance implementing an antimicrobial stewardship program: guidelines by the infectious diseases society of america and the society for healthcare epidemiology of america guidance for the knowledge and skills required for antimicrobial stewardship leaders inpatient antimicrobial stewardship on pediatrics: a systematic review making a case for pediatric antimicrobial stewardship programs antimicrobial stewardship challenges in a referral neonatal intensive care unit antimicrobial stewardship in the nicu bloodborne pathogens and needlestick prevention viral hepatitis transmission in ambulatory health care settings hepatitis c virus outbreaks in hemodialysis centers: a continuing problem updated us public health service guidelines for the management of occupational exposure to human immunodeficiency virus and recommendations for postexposure prophylaxis the effect of universal glove and gown use on adverse events in intensive care patients contact precautions: more is not necessarily better contamination of health care personnel during removal of personal protective equipment the increasing visibility of the threat of health care worker self-contamination prevention strategies for seasonal influenza in healthcare settings the role of the surface environment in healthcare-associated infections evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings improving healthcare environmental cleaning and disinfection: current and evolving issues disinfecting personal protective equipment with pulsed xenon ultraviolet as a risk mitigation strategy for health care workers copper continuously limits the concentration of bacteria resident on bed rails within the intensive care unit disinfection and sterilization: an overview the healthcare infection control practices advisory committee (hicpac) multisociety guideline on reprocessing flexible g.i. endoscopes: 2011 ercp scopes: what can we do to prevent infections? how to assess risk of disease transmission to patients when there is a failure to follow recommended disinfection and sterilization guidelines guidelines for environmental infection control in health-care facilities. recommendations of cdc and the healthcare infection control practices advisory committee (hicpac) free vaccine programs to cocoon high-risk infants and children against influenza and pertussis isolation precautions for visitors animals in healthcare facilities: recommendations to minimize potential risks multistate outbreak of human salmonella poona infections associated with pet turtle exposure-united states the detection of monkeypox in humans in the western hemisphere exposure to nontraditional pets at home and to animals in public settings: risk to children interferon-gamma release assays for diagnosis of tuberculosis infection and disease in children influenza vaccination coverage among health care personnel-united states, 2014−15 influenza season revised shea position paper: influenza vaccination of healthcare personnel policy statement: recommendations for mandatory influenza immunization of all healthcare personnel carrots and sticks: achieving high healthcare personnel influenza vaccination rates without a mandate mandatory influenza vaccination of health care workers: translating policy to practice employee designation and health care worker support of an influenza vaccine mandate at a large pediatric tertiary care hospital zika virus centers for disease control and prevention. updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (tdap) in pregnant women-advisory committee on immunization practices (acip) molecular characterization of strains of respiratory syncytial virus identified in a hematopoietic stem cell transplant outpatient unit over 2 years: community or nosocomial infection? epidemiology of community-acquired methicillin-resistant staphylococcus aureus skin infections among healthcare workers in an outpatient clinic infection prevention and control in pediatric ambulatory settings guide to infection prevention for outpatient settings: minimum expectations for safe care safe living after hematopoietic cell transplantation shea guideline: infection prevention and control in residential facilities for pediatric patients and their families impact of infection prevention and control initiatives on acute respiratory tract infections in a pediatric long-term care facility