key: cord-0728856-uw8qxw74
authors: Xiao, Jian; Fang, Min; Chen, Qiong; He, Bixiu
title: SARS, MERS and COVID-19 among Healthcare Workers: A Narrative Review
date: 2020-05-27
journal: J Infect Public Health
DOI: 10.1016/j.jiph.2020.05.019
sha: 5919b03f1dda3267874b4c698178d9ab31a6ec4e
doc_id: 728856
cord_uid: uw8qxw74

Abstract In the recent two decades, three global viral infectious diseases, severe acute respiratory syndrome (SARS), middle east respiratory syndrome (MERS), and coronavirus disease (COVID-19), have occurred worldwide. SARS occurred in November 2002, causing 8,096 infected cases, as well as 774 deaths. MERS occurred in June, 2012, causing 2,519 confirmed cases, along with 866 associated deaths. COVID-19 occurred in December 2019, as of 30 April 2020, a total of 3,024,059 clinical cases have been reported, including 208,112 deaths. Healthcare workers (HCWs) need to be in close contact with these virus-infected patients and their contaminated environments at work, thus leading to be infected in some of them, even a few of them are died in line of duty. In this review, we summarized the infection status of HCWs during the outbreak of SARS, MERS and COVID-19, with in-depth discussion, hoping to provoke sufficient attention to the HCWs infection status by more people.

Viral infectious diseases have always been a threat to human survival. In the recent two decades, three global viral infectious diseases, severe acute respiratory syndrome (SARS), middle east respiratory syndrome (MERS), and the current coronavirus disease [1] [2] [3] , have occurred worldwide, and all the pathogens are the types of coronavirus [4] .

The pathogen of SARS is named as severe acute respiratory syndrome coronavirus (SARS-CoV) [5] . It first occurred in November 2002, and originated from Guangdong province, southern China [6] . According to the aggregate data of WHO, a total of 8,096 cases were reported, resulting in 774 deaths (the case-fatality ratio is 9.56%) in 26 countries on 5 continents during the SARS epidemic [7] .

The pathogen of MERS is named as middle east respiratory syndrome coronavirus (MERS-CoV) by the Coronavirus Study Group (CSG) [8] . The virus was first isolated from a patient that died of the disease in June, 2012, in Jeddah, Saudi Arabia [9] . According to the summary of WHO, at the end of January 2020, a total of 2,519 confirmed MERS cases, including 866 associated deaths (the case-fatality rate is 34.38%), have been reported globally [10] .

China [11] . Soon afterwards, based on phylogeny, taxonomy and established practice, the CSG named the pathogen of COVID-19 as SARS-CoV-2 [12] . As of 30 April 2020, a total of 3,024,059 confirmed cases have been reported globally, including 208,112 deaths (the case-fatality ratio is about 6.88%) [13] .

Healthcare workers (HCWs) are defined as personnel responsible for direct treatment, care, service or help of patients, mainly consisting of doctors and nurses, as well as physiotherapists, laboratory technicians, respiratory therapists, housekeepers, or even medical waste handlers [14] [15] [16] . HCWs need to be in close contact with these virus-infected patients and their contaminated environments at work, so they are at great risk of job exposure. In this study, we aim to review the infection status of HCWs in the past battles of SARS and MERS, and to summarize the infection status [18] .

Most of the probable SARS cases (57.14%, 36/63) identified in the Vietnam outbreak were HCWs, all of which occurred in a private hospital in Hanoi [19] , and lack of SARS transmission among the public HCWs [20] . L Clifford McDonald and colleagues [21] reported that 164 HCWs in the greater Toronto area were infected with SARS, which is more than the total number of infected HCW in Canada as summarized by WHO (Table 1) . However, the reason for the inconsistency in the total number of these reports may be that the former involved suspected cases [ conducting a retrospective analysis. Therefore, it can be speculated that the current number of HCW cases infected with MERS may be more than 450 (Table 2) .

South Korea has the largest number of MERS infections outside Saudi Arabia in the world, with 186 confirmed cases [26] . Among them, 25 cases were occupationally acquired by HCWs, accounting for 13.44% (25/186) of total infection cases in South Korea [27] ( Table 2 ). The super-spreader of MERS-CoV is the main cause of MERS outbreak and infection of HCW in South Korea. Having followed a single patient exposure in a hospital in South Korea, Sun Young Cho and colleagues [28] found 82 individuals were infected with MERS-CoV from a super-spreader, and 8 of them were

HCWs. 

China has 84,369 COVID-19 cases with of 4,643 deaths as of 30 April 2020 [13] .

Since the outbreak of COVID-19, the infection among HCWs has been reported gradually in China. By extracting data regarding 1,099 patients with laboratory-confirmed COVID-19, Wei-Jie Guan and colleagues found a total of 3.5%

(about 38 of 1,099) confirmed cases are HCWs [29] . Dawei Wang and colleagues reported that 40 HCW infected cases among 138 hospitalized patients [30] 

Hospital is the important place for secondary transmission of SARS, MERS and COVID-19 [14, 38, 39] . Densely staffed, and packed with public facilities and people [41] . Studies suggest that when no eye protection was worn, SARS-CoV-2 could also possibly be spread by aerosol contact with conjunctiva and cause infection of HCWs [42] [43] [44] . Close proximity between patients and ophthalmologists during slit lamp examination, intraocular pressure measurement, direct ophthalmoscopy, pupillary dilatation and others may pose an infectious risk to ophthalmologists [44] .

Hence these factors may increase the risk of cross-infection between HCWs and patients in the department of ophthalmology.

Nosocomial transmission of SARS, MERS and COVID-19 can be categorized as patient-to-patient, patient-to-HCW, HCW-to-patient, and HCW-to-HCW. Confirmed or suspected cases of these infectious diseases can be physically separated by setting up isolation wards or establishing isolation hospitals to avoid patient-to-patient transmission [38, 45, 46] . Therefore, the subsequent key issue that needs to be persistently considered, solved and prevented is how to prevent the transmission of patient-to-HCW. are facing the super-spreader, whose transmission ability is simply overwhelming [47] [48] [49] . Therefore, how to identify the super-spreaders as early as possible is of vital importance as to reducing the chance of patient-to-patient and patient-to-HCW transmission.

Hand hygiene is recognized as an easy and effective way to prevent the spread of respiratory infections that include SARS, MERS and COVID-19 [38, [50] [51] [52] .

Correspondingly, wearing masks is the simplest and most important PPE to prevent infection of these infectious diseases. Both surgical and N95 masks can effectively prevent HCWs from being infected with SARS, MERS and COVID-19. However, if conditions permit, wearing N95 masks maybe relatively better [53] [54] [55] [56] [57] . Other PPE such as gloves, hats, protective clothing, isolation clothing and others are also important for

HCWs to prevent infection, depending on the working environment. Improving the compliance of using PPE and standardizing the putting on and taking off process of these PPEs can better protect HCWs.

By investigating the frontline of HCWs combating SARS, Cindy W C Tam and colleagues reported that the stress and psychological distress among HCWs were high, accounting for 68% and 57% respectively [58] . Robert Maunder also reported that a high level of distress was experienced by 29-35% of HCWs, and the relevant contextual factors were having contact with SARS patients, being a nurse and having children [59] . Similarly, study conducted by Namhee Oh and colleagues reported that high stress had also shown in HCWs engaged in patient nursing during the MERS outbreak [60] . Dae Hyun Um and colleagues found that 26.6% doctors involved in MERS care showed symptoms of depression [61] .

Recently, Jinghua Li and colleagues [62] reported the prevalence of depression J o u r n a l P r e -p r o o f patients were associated with a higher risk of depression, anxiety, insomnia and distress. HCWs were anxious regarding their safety and reported psychological effects from mortality reports from COVID-19 infection [64] . Therefore, hospital administrators need to pay sufficient attention to and ease the stress and psychological distress on frontline HCWs fighting the COVID-19 epidemic.

Previous studies have found that some HCWs developed post-traumatic stress syndrome after coping with SARS or MERS outbreaks [65] [66] [67] [68] . Because of perceived risk of fatality from SARS, increased work stress, and affected social relationships,, some HCWs were even considered switching or resigning from their job [69] . These previous evidences remind hospital managers, that during the outbreak of COVID-19, The pandemic of COVID-19 gave medical students a big practical lesson. The

Chinese Ministry of Education has postponed the spring start of colleges and universities and discourages medical students from returning to hospitals for internships before the outbreak is under control [75] . Italy government has announced a plan to add 20,000 new HCWs to meet the demand to fight against COVID-19, and called on students who have completed their medical degrees and are in the final year of specialist training to participate [76] . The England chief medical officer has announced that the final year medical students may have their duty rights extended [77] . Anyway, governments have made appropriate arrangements for medical students in their countries according to their own epidemic situation.

However, on the other hand, we also need to consider whether the COVID-19 epidemic has affected the future career planning of medical students, and whether it has caused a psychological burden and discouraged them from engaging in the medical industry in the future. In the face of the current global epidemic disaster, and alike major outbreaks that may also occur in the future, we should encourage medical students in a suitable way to strengthen their confidence in the medical industry, and encourage young people to choose to study medicine. 

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