23 April 2020

COVID-19: Social distancing and the impact of the pandemic on healthcare professionals

Stressed doctor_Porterhouse Medical Advisory Group

 

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a member of the coronavirus family, is the pathogen responsible for causing coronavirus disease 2019 (COVID-19) in infected individuals. The effects of contracting SARS-CoV-2 are wide-ranging in severity; the infection can be asymptomatic or can result in symptoms such as fever, cough or shortness of breath. In some cases, symptoms can be severe and life-threatening. The elderly and those with underlying health conditions have been identified as high-risk groups; however, healthy individuals of all ages have lost their lives in the battle against COVID-19 [1]. As of 22 April 2020 in the UK, 133,495 people have tested positive for SARS-CoV-2 and 18,100 of those hospitalised who tested positive for the virus have died [2].

Initially, the advice from the UK government and Public Health England was to adopt rigorous hygiene measures, such as regular handwashing, and to self-isolate if you had been in direct contact with a confirmed case or if you displayed COVID-19 symptoms upon returning from specific high-risk regions [3, 4]. In an attempt to slow the spread of this infection, additional social distancing measures have been implemented in the UK. A nationwide lockdown began on 23 March 2020, with people only allowed to leave their homes to shop for essential items; seek medical care; exercise once a day; or travel to and from work if working from home is not possible. The guidance also states that people should stay 2 metres away from anyone who is not from their household [4, 5].

The aim of these measures is to slow the spread of SARS-CoV-2, flatten the height of the infection curve and gradually build herd immunity. This will provide more time to increase capacity for hospital beds and SARS-CoV-2 testing, and to find effective treatments or a vaccine. The social and economic costs of implementing such strict measures are high; however, the ultimate aim is to relieve the pressure on the NHS so that it is better equipped to treat affected individuals moving forward [6, 7].

Although much has been said of the essential role that healthcare professionals (HCPs) are playing in treating patients on the front line of the pandemic, there remains a need to explore the extent of the impact that this unprecedented time is having on them. It is critical that we not only acknowledge the physical health risks associated with increased exposure to the virus but also understand the potential mental health consequences of working under such difficult conditions. In China, a survey conducted on over 1,200 HCPs treating patients with COVID-19 reported significant rates of psychological symptoms, with approximately 50%, 45% and 34% of participants reporting symptoms of depression, anxiety and insomnia, respectively. A staggering 72% of participants reported some form of psychological distress. Female HCPs, nurses, those with intermediate seniority roles and those working on the front line at the centre of the epidemic in Wuhan were identified as having the greatest risk of developing symptoms [8].

Moral injury is a concept that may partly explain the increased risk of mental health conditions in HCPs who are at the forefront of the pandemic. In the context of healthcare, this term describes the effect on clinicians who feel as though they have not performed as well as they should have when treating patients. Although clinicians struggle with moral injury on a daily basis (particularly when systemic barriers to treatment are encountered in the resource-constrained NHS), this has been heightened by the SARS-CoV-2 outbreak and the increasing demand for care [9]. There are a limited number of intensive care beds and ventilators in the UK, and while efforts are being made to flatten the curve in order to increase hospital capacity and equipment availability, clinicians will need to make difficult decisions about the allocation of medical supplies and resources for reasons that are entirely out of their control [6, 9]. Additional factors contributing to the increased risk of moral injury in HCPs are the lack of understanding of clear therapeutic options for the treatment of patients beyond supportive care, and the lack of ready access to testing for HCPs. The latter has resulted in clinicians who may not be infected with the virus having to self-isolate if they or a member of their household exhibit symptoms, preventing them from treating patients with COVID-19 [10, 11].

Resilience, perhaps the most important tool HCPs have at their disposal to combat moral injury and mental health conditions, may also be lower than normal under current circumstances. Reduced resilience may partly be due to the emotional strain and worry HCPs have of becoming infected themselves or transmitting the virus to their families [9]. This is made increasingly likely because of the current worry about access to personal protective equipment (PPE) in the UK [12]. In order to counter this, some HCPs have moved out of their homes to protect their loved ones; however, removal from their support networks may compound the risks to their mental health.

The future remains uncertain because of the difficulty in modelling the likely course of the disease. Until epidemiologists are able to calculate the transmission rate of the virus and determine whether this will be the same year-round or change seasonally, it is difficult to predict the advice that will be given to the nation in terms of social distancing. It has been suggested that if the transmission rate remains the same year-round, one prolonged period of social distancing may be sufficient to flatten the curve; however, if the virus is seasonal, multi-cycle social distancing may be more appropriate. This strategy would involve multiple periods of social distancing throughout the year until the infection curve dips below the level at which it is deemed safe for normal social activities to resume. Multi-cycle social distancing would result in multiple peaks of infection, but the height of these peaks and the number of cases would be moderated in such a way that the NHS would theoretically not become overwhelmed [6].

Although the challenges of social distancing and the uncertainty of the future may potentially have negative effects on the mental health of those of us in lockdown, we need to remind ourselves that the current guidance is in our best interests. The only way that we will combat this global health crisis is if each of us does our part – however insignificant that may seem. NHS rainbowSo, stay at home, protect the NHS and save lives. It is the least we can do for the HCPs who are risking so much to keep us safe.

References

  1. Mayo Clinic. Coronavirus disease 2019 (COVID-19). Available at: https://www.mayoclinic.org/diseases-conditions/coronavirus/symptoms-causes/syc-20479963. Accessed April 2020.
  2. UK. Number of coronavirus (COVID-19) cases and risk in the UK. Available at: https://www.gov.uk/guidance/coronavirus-covid-19-information-for-the-public#history. Accessed April 2020.
  3. UK. Coronavirus (COVID-19): What is self-isolation and why is it important? Available at: https://publichealthmatters.blog.gov.uk/2020/02/20/what-is-self-isolation-and-why-is-it-important/. Accessed April 2020.
  4. National Health Service. Advice for everyone: Coronavirus (COVID-19). Available at: https://www.nhs.uk/conditions/coronavirus-covid-19/. Accessed April 2020.
  5. UK. PM address to the nation on coronavirus: 23 March 2020. Available at: https://www.gov.uk/government/speeches/pm-address-to-the-nation-on-coronavirus-23-march-2020. Accessed April 2020.
  6. COVID-19 and the science of social distancing. Available at: https://www.medscape.com/viewarticle/927613. Accessed April 2020.
  7. American Society for Microbiology. Researchers investigate potential treatments for COVID‑19. Available at: https://www.asm.org/Press-Releases/2020/Researchers-Investigate-Potential-Treatments-for-C. Accessed April 2020.
  8. Lai J, Ma S, Wang Y et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020; 3 (3): e203976.
  9. How UK doctors are coping with anxiety/distress during COVID-19. Available at: https://www.medscape.com/viewarticle/927543#vp_1. Accessed April 2020.
  10. Thornton J. Covid-19: How coronavirus will change the face of general practice forever. BMJ 2020; 368: m1279.
  11. British Medical Association. Priority Covid-19 testing for healthcare staff ‘long overdue’, says BMA. Available at: https://archive.bma.org.uk/news/media-centre/press-releases/2020/march/priority-covid-19-testing-for-healthcare-staff-long-overdue-says-bma. Accessed April 2020.
  12. British Medical Association. BMA survey finds doctors’ lives still at risk despite government pledges on PPE. Available at: https://www.bma.org.uk/news-and-opinion/bma-survey-finds-doctors-lives-still-at-risk-despite-government-pledges-on-ppe. Accessed April 2020.
  • Article updated 27/4/2020 to reflect current concerns on PPE and testing