key: cord-0839741-dq6oyvjn authors: Abid, D. A.; Shahzad, D. H.; Khan, D. H. A.; Piryani, D. S.; Khan, A. R.; Rabbani, D. F. title: Perceived Risk and Distress related to COVID-19: Comparing Healthcare versus non-Healthcare Workers of Pakistan date: 2020-10-27 journal: nan DOI: 10.1101/2020.10.23.20218297 sha: 51c62eb9eafa9b07ff2e01d99cdaa165152809a5 doc_id: 839741 cord_uid: dq6oyvjn Background Healthcare workers (HCWs) find themselves susceptible to contracting COVID-19 or being the source of exposure for their family members. This puts them at a high risk of psychological distress which may compromise patient care. In this study we aim to explore the risk perceptions and psychological distress between HCWs and non-healthcare workers (NHCWs) in Pakistan. Methods A cross-sectional study was conducted in Pakistan using an online self-administered questionnaire. Respondents were categorized into HCWs (completed or aspiring to complete education in Medicine or allied fields) and NHCWs. HCWs were further categorized into front-line (direct patient care) and back-end HCWs. Results Data from 1406 respondents (507 HCWs and 899 NHCWs) was analyzed. No significant difference was observed between HCWs and NHCWs perception of susceptibility and severity towards COVID-19. Healthcare graduates perceived themselves (66% students vs. 80% graduates, p-value 0.011) and their family (67% students vs. 82% graduates, p-value 0.008) to be more susceptible to COVID-19 than the healthcare students. Frontline HCWs perceived themselves (83% frontline vs. 70% back-end, p-value 0.003) and their family (84% frontline vs. 72% back-end, p-value 0.006) as being more susceptible to COVID-19 than back-end healthcare professionals. Over half of the respondents were anxious (54% HCWs and 55% NHCWs). Female gender, younger age and having COVID-19 related symptoms had a significant effect on the anxiety levels of both HCWs and NHCWs. Conclusion Frontline HCWs, healthcare students, young people, females and individuals with lower income were at a higher risk of psychological distress due to the pandemic. Government policies should thus be directed at ensuring the mental well-being of frontline HCWs, and improving their satisfaction in order to strengthen health care delivery system. regarding the well-being of family members. Increased anxiety and depression among frontline 62 healthcare professionals is a common feature in epidemics (8, 9) . Moreover, there are disparities in 63 terms of psychological impact due to COVID-19 within HCWs depending on their level of patient 64 care. In a study conducted in Singapore the psychological distress, depression, anxiety, and stress 65 experienced by health care workers during the COVID-19 outbreak, frontline nurses had significantly 66 lower vicarious traumatization scores than non-frontline nurses and the general public (10). Another 67 recent study among healthcare professionals in a tertiary infectious disease hospital for COVID-19 in 68 China also revealed a high incidence of anxiety and stress disorders among frontline medical staff, 69 with nurses having a higher incidence of anxiety than doctors (11). 70 The scale of the current health crisis is a bigger concern in a resource-limited country like Pakistan, 71 where it may significantly compromise the quality of care and health care services. These 72 unprecedented times call for an increased need to gauge the knowledge and protective behaviors of 73 people at different levels of health care services. Unduly high anxiety levels and poor-risk 74 perceptions often result in barriers to healthcare providers' willingness and ability to work and 75 constitute an important component in policy-related decisions (12,13). While data is limited on the 76 impact of COVID-19 with regards to barriers to working, it is indicated that healthcare providers are 77 likely to suffer from high levels of anxiety and post-traumatic stress disorders (14) . 78 Prevention remains the mainstay in the treatment and containment of the pandemic, requiring people 79 at large to practice COVID-19 mitigating behaviors. Significant efforts hence need to be undertaken 80 to strengthen beliefs about the disease in the population including the severity and susceptibility of 81 threat so that people are more likely to take the needed actions to reduce the damage caused by the 82 disease. As a result, it becomes important to study these key indicators to evaluate the public sense 83 level of education, household income, permanent city of residence, and travel history followed by 129 their health status in the past 14 days and whether they experienced any symptoms of illness. 130 Next, they were asked to rate the severity of the symptoms caused by COVID-19 and their perceived 131 chance of survival if infected with COVID-19. Responses were captured using a five-point Likert 132 scale. Subsequently, information exposure was probed by asking respondents about the sources from 133 which they obtain information about COVID-19, and how reliable they deemed those sources to be. was cleaned, coded, and analyzed using SPSS. A descriptive analysis was performed and results were 145 tabulated as numbers (percentages) for qualitative variables and mean (±standard deviation) for 146 quantitative variables. The Independent t-test or Mann Whitney U test or Pearson Chi-square test was 147 applied to assess the differences between the groups' (healthcare vs. NHCWs, healthcare students vs. 148 graduates, frontline vs. back-end HCWs) perception of susceptibility and severity towards COVID-149 19, anxiety and depression level, the psychological impact of COVID-19, adoption of precautionary 150 measures, reliability of information sources, and satisfaction with government measures. Bivariate 151 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint and multivariate binary logistic regression analyses were performed to identify predictors (age, 152 gender, household income, and presence of symptoms) of anxiety and depression among HCWs and 153 NHCWs. Initially, in bivariate analysis, a single predictor at a time was entered and crude odds ratio 154 (OR) and 95% confidence intervals (CI) were subsequently computed. A multivariate analysis, with 155 all predictors entered at the same time, was completed to adjust for the effect of confounding, and 156 adjusted OR and 95% CI were computed. All statistical tests were two-sided and a p-value of ≤ 0.05 157 was considered to be statistically significant. 158 Ethical approval was obtained from the Ethical Review Committee (ERC) of the Aga Khan 160 University, Pakistan. Participants were asked to present their consent at the beginning of the survey 161 and were free to withdraw at any stage. 162 Data from 1406 respondents (507 HCWs and 899 NHCWs) was analyzed. Majority of the 164 respondents were males (53% HCWs and 72% NHCWs), below the age of 35 years (78% HCWs and 165 61% NHCWs), were residents of Karachi (49% HCWs and 50% NHCWs), and had a household 166 income of ≤ PKR 40,000 (22% HCWs and 27% NHCWs) (Refer to Table 1 ). More than half of the 167 HCWs (54%) belonged to the field of Medicine and 36% were currently working in a hospital, ward 168 or a clinic (Refer to Table 2 ). 169 and severity towards COVID-19. About three-fourths of the respondents perceived that they (75% 172 HCWs and 71% NHCWs) and their families (77% HCWs and 71% NHCWs) might get sick if they 173 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint do not take preventive measures. Similarly, several respondents considered the symptoms of COVID-174 19 (if infected) as serious (46% HCWs and 38% NHCWs). Furthermore, most respondents thought 175 that one could survive a COVID-19 infection (HCWs 70% and NHCWs 66%). However, a 176 statistically significant difference was seen between the healthcare students' and graduates' 177 perception of susceptibility and severity towards COVID-19. Healthcare graduates perceived 178 themselves (66% students vs. 80% graduates, p-value 0.011) and their family (67% students vs. 82% 179 graduates, p-value 0.008) to be more susceptible to COVID-19 than the healthcare students. 180 Similarly, compared to students, more graduates perceived the disease to be severe (p-value 0.040). 181 A significant difference was also seen between frontline and back-end HCWs' perception of 182 susceptibility and severity towards COVID-19. Frontline HCWs perceived themselves (83% frontline 183 vs. 70% back-end, p-value 0.003) and their family (84% frontline vs. 72% back-end, p-value 0.006) 184 as being more susceptible to COVID-19 than back-end HCWs. However, compared to those on the 185 frontline, more back-end HCWs perceived the disease to be severe (p-value 0.045) (Refer to Table 186 3). 187 Over half of the respondents were found to be either anxious (54% HCWs and 59% NHCWs) or 189 depressed (54% HCWs and 57% NHCWs) as indicated by the HADS scores. No significant 190 difference was seen in the anxiety and depression levels of HCWs and NHCWs. However, the 191 incidence of depression was significantly higher among healthcare students compared to healthcare 192 graduates (Mean (SD): 8.40 (3.45) in students 7.72 (3.80) in graduates, p-value 0.047). Around 62% 193 of healthcare students and 49% of graduates had depression. A statistically significant difference was 194 noted between frontline and back-end HCWs' perception about the impact of COVID-19 on their 195 personal life (75% frontline vs. 58% back-end HCWs, p-value <0.001). However, no significant 196 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 27, 2020. difference was reported between HCWs' and NHCWs' perceived impact of COVID-19 on their jobs, 197 personal life, sleeping pattern, and eating habits (Refer to . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint Significantly more HCWs reported wearing face masks (94% HCWs vs. 91% NHCWs, p-value 221 0.012), avoiding visiting meat shops or markets (77% HCWs vs. 66% NHCWs, p-value <0.001) than 222 NHCWs. Moreover, significantly less HCWs reported that they refrain from going to hospitals or 223 clinics (60% HCWs vs. 81% NHCWs, p-value <0.001) and work (55% HCWs vs. 66% NHCWs, p-224 value<0.001) compared to NHCWs. Additionally, there was a statistically significant difference 225 between healthcare students' and graduates' adoption of some precautionary measures such as 226 washing their hands with soap/sanitizer frequently (96% students vs. 99% graduates, p-value 0.001), 227 avoiding going out (87% students vs. 73% graduates, p-value 0.003), refraining from going to 228 hospital or clinic (80% students vs. 50% graduates, p-value <0.001) Similarly, a statistically 229 significant difference was noted between frontline and back-end HCWs in the adoption of some 230 precautionary measures such as washing their hands with soap/sanitizer frequently (100% frontline 231 vs. 97% back-end, p-value 0.009, refraining from going to hospital or clinic (45% frontline vs. 72% 232 back-end, p-value<0.001) and avoiding going to work (37% frontline vs. 68% back-end, p-233 value<0.00)1 (Refer to Table 6 ). 234 Nearly all HCWs and NHCWs remained alert to the disease progression of COVID-19 (96% for the 236 former and 95% of the latter). The most trusted sources of information were doctors (91% HCWs and 237 87% NHCWs, p-value 0.003) and government websites (85% HCWs and 80% NHCWs, p-value 238 0.056). Furthermore, significantly more NHCWs considered magazine (39% HCWs vs. 44% 239 NHCWs, p value 0.005), television (54% HCWs vs. 63% NHCWs, p value 0.043), family or friends 240 (46% HCWs vs. 54% NHCWs, p value 0.001) as reliable sources of information. Likewise, a 241 statistically significant percentage of healthcare students considered official government websites 242 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint (86% students vs. 84% graduates), television (60% students vs. 51% graduates, p-value 0.040), radio 243 (58% students vs. 44% graduates, p-value; 0.017), and magazine (50% students vs. 33% graduates, p-244 value; 0.015) as reliable sources of information compared to healthcare graduates. Moreover, 245 compared to back-end HCWs, more frontline HCWs believed in the reliability of information 246 received through television (47% frontline vs. 59% back-end, p-value 0.049), radio (42% frontline 247 vs. 54% back-end, p-value 0.046), newspaper (49% frontline vs. 62% back-end, p-value 0.015), and 248 magazine (28% frontline vs. 47% back-end, p-value 0.015) (Refer to Table 7) . 249 Less than a third of HCWs and NHCWs were satisfied with the government's measures to control 251 COVID-19. HCWs, in comparison with NHCWs, were significantly more dissatisfied with the 252 availability of Personal Protective Equipment (62% vs. 46%, p value <0.001), testing kits (49% vs. 253 41%, p value 0.028), and screening facilities (54% vs. 42%, p value <0.001). Similarly, compared to 254 healthcare students, graduates were significantly more dissatisfied with screening facilities (57% 255 graduates vs. 49% students, p-value0.016), testing kits (52% graduates vs. 43% students, p-value 256 0.016), and quarantine facilities (49% graduates vs. 38% students, p-value 0.012). However, no 257 significant difference was seen between frontline and back-end HCWs' satisfaction with 258 government's measures to control COVID-19 (Refer to Table 8 ). 259 The COVID-19 pandemic has caused a global health crisis. As the disease burden exponentially 261 increases, HCWs find themselves susceptible to contracting the disease or being the source of 262 exposure for their family members. This constant threat puts them at a high risk of psychological 263 distress. This study explores the similarities and differences in risk perceptions, anxiety levels, and 264 behavioral responses of HCWs and NHCWs in Pakistan during the COVID-19 pandemic. 265 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint Respondents' adoption of precautionary measures and satisfaction with the government's response 266 were also assessed. 267 This study showed that the perceived susceptibility and severity towards COVID-19 was high in both 268 HCWs and NHCWs. Healthcare graduates perceived themselves and their families to be more 269 susceptible to COVID-19 and found the disease to be much more severe than healthcare students. A 270 study from Hong Kong showed an even higher perception of susceptibility and severity towards 271 COVID-19 (15,16). The generally high-risk perception levels can be explained by the coverage of the 272 pandemic on social media as well as television sensitizing the people to the disease. Frequency of 273 watching the media and sources of information has been known to influence risk perception (17). 274 This is supported by reports from the MERS, SARS and H1N1 outbreaks (18,19). 275 Additionally, frontline HCWs perceived themselves and their families to be more susceptible to 276 COVID-19 than back-end HCWs while the latter perceived the disease to be more severe. Similar to 277 HCWs in this study, training status and clinical placement creates differences in risk perception, as 278 seen in the medical students of Iran (20). This indicates that HCWs felt more vulnerable with greater 279 exposure to the infected individuals. Direct contact with COVID-19 patients is hence a major cause 280 for concern among HCWs for themselves and their families. Greater perceived severity among 281 backend workers on the other hand may be explained by the fact that since these workers are not 282 seeing patients recover as frequently, their notion of disease severity is higher. 283 More than half the respondents in the study had some form of psychological distress (anxiety or 284 depression). Data describing gaps in anxiety levels between HCWs and NHCWs is limited. Contrary 285 to this study, which showed that both HCWs and NHCWs had similar high anxiety levels, HCWs in 286 Italy reported higher anxiety levels in comparison to the general population (21). Therefore, the gap 287 in anxiety levels seen in Italy (between HCWs and general population) is not seen in Pakistan. This 288 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint Pakistan reported a lower disease burden compared to Italy, therefore it is possible that the HCWs in 289 Pakistan are generally less anxious due to a lesser case load and severity at the time of data 290 collection. A possible reason for higher anxiety levels in the NHCWs group in this study could be 291 due to higher sensitization by the social media creating undue anxiety. Another possible reason for 292 higher anxiety levels in the NHCWs group in this study could be a higher average education level 293 (Bachelor's) which is an independent risk factor for elevated anxiety symptoms (22). 294 Both HCWs and NHCWs had similar perceptions of the impact of COVID-19 on their daily routine. 295 The perceived impact, however, was greater among frontline HCWs compared to the back-end 296 HCWs. Frontline HCWs (doctors and nurses) are involved in more direct patient care and have 297 greater patient interaction. New protocols and added personal protective equipment (PPE) are 298 focused on frontline workers more which warrants a greater transition from the pre-pandemic life. 299 While backend HCWs (pharmacists, dentists, physiotherapists, allied health sciences, and students) 300 also had additions in their daily routine such as masks, social distancing, and hand sanitizing, these 301 changes are comparatively less cumbersome compared to changes in frontline HCW's routines. The 302 greater the patient interaction, greater number of precautions are required in daily routine which 303 results in greater impact on personal lives. A study reported nurses having more anxiety in 304 comparison to doctors as they are involved for a longer duration with the patients (23). Additionally, 305 frontline HCWs perceived themselves and their families to be more susceptible to COVID-19 than 306 back-end HCWs while the latter perceived the disease to be more severe. Greater perceived severity 307 among backend workers on the other hand may be explained by the fact that since these workers are 308 not seeing patients recover as frequently, their notion of disease severity is higher. 309 This study pointed out that healthcare students were more depressed than the graduates. Existing data 310 that has generally shown students as a high risk group for depression (24). Experiences from the past 311 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint epidemics also provide similar evidence (25-27). All educational institutes in Pakistan were closed 312 during the duration of the study. Although educational institutes adapted to online classes and virtual 313 examinations, it took a long while before students could get used to new routines and methods. These 314 interruptions in schedules, lack of physical interaction with peers and social isolation may have 315 contributed to the greater depression levels. Furthermore, students are often more active on social 316 media which has been a great source of information and sensitization of COVID-19 pandemic. COVID-19 has also increased the financial burden on households as many people struggle to run 332 small businesses and maintain daily income. The fear of not being able to fulfil the basic necessities 333 may be the reason why lower income can increase anxiety levels. The results, therefore, suggest the 334 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The main strength of this study is the comparison of various sub-groups within HCWs for a 346 comprehensive analysis. In this respect, it is a novel study accounting for differences in experiences 347 among HCWs. However, frontline and back-end categorization was made without using any standard 348 classification. Moreover, in this study, most of the respondents were aged less than 35 years, which 349 may not accurately represent the older population who are at greater risk for contracting COVID-19. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint monitored on a regular basis to avoid burnout. Incentives such as financial bonuses and paid leaves 358 should be provided. To cater for the individual needs of the population, communities should establish 359 online mental health and wellness groups to overcome social isolation. Government should ensure 360 provision of PPE, testing kits, and screening facilities to increase satisfaction levels of HCWs in 361 particular and the public at large. Furthermore, implementing these strategies may also contribute in 362 mitigating the disease spread. The better the disease is controlled, the lesser will be the psychological 363 morbidity and adverse impact on people's lives. 364 HCWs and NHCWs both have high levels of perceived susceptibility and severity along with 366 increased psychological distress. This study also identified vulnerable groups such as frontline 367 HCWs, healthcare students, younger aged people, females, and individuals with lower income to be 368 at a higher risk of psychological distress. We recommend exploring other vulnerable groups not 369 evaluated in this study such as COVID-19 positive patients, older and immunocompromised patients 370 for risk perceptions and psychological distress. Further studies need to investigate a direct link 371 between HCWs and the development of COVID-19 infection to quantify the infection risk. HCWs 372 are the frontline fighters against pandemics and preventing their psychological morbidity must be 373 prioritized for ensuring their well-being as well as that of patients that they treat within the health 374 care system. 375 The authors declare that the research was conducted in the absence of any commercial or financial 377 relationships that could be construed as a potential conflict of interest. 378 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint FR conceived the study, guided data collection and reviewed all drafts of the manuscript. AA and HS 380 adapted the questionnaires and wrote the manuscript. SP analyzed and narrated the data. HAK and 381 ARK edited and revised multiple drafts of the manuscript. ARK also assisted in adapting the 382 questionnaires and posting it on social media channels of AKU. All authors reviewed and endorsed 383 the final submission. 384 The authors did not receive any direct funding for the purpose of this study. 386 from: https://gallup.com.pk/economic-impact-of-covid-19-lockdown-on-pakistani-households/ 399 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 27, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 27, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 27, 2020. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint Note: Categories were merged, so "agree/severe/high" and "strongly agree/ very severe/ very high" were merged into category 494 "agree/severe/high", and categories "disagree/ not severe/ not high" and "strongly disagree/ not severe at all/ not high at all" were 495 merged into "disagree/ not severe/ not high". . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 27, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint 508 Note: Percentages of categories "reliable/ very reliable" were merged into category "reliable", and categories "unreliable / very 509 unreliable" were merged into "unreliable". . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 27, 2020. Note: Only the most salient variables have been reported in this table. Percentages of categories "satisfied" and "very satisfied" were 513 merged into category "satisfied /very satisfied", and categories "unsatisfied" and "very unsatisfied" were merged into 514 "unsatisfied/very unsatisfied". . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 27, 2020. ; https://doi.org/10.1101/2020.10.23.20218297 doi: medRxiv preprint Outbreak of pneumonia of unknown etiology in Wuhan, China: 390 The mystery and the miracle Rolling updates on coronavirus disease (COVID-19) COVID-19 Health Advisory Platform by Ministry of National Health Services Regulations and 395 The authors would like to thank all the respondents of the survey from across Pakistan. 388