key: cord-0938621-dtoheyo4
authors: Qi, Jing; Xu, Jing; Li, Bozhi; Huang, Jinsha; Yang, Yuan; Zhang, Zhentao; Yao, Dongai; Liu, Qunhui; Jia, Min; Gong, Daokai; Ni, Xiaohong; Zhang, Qimei; Shang, Furong; Xiong, Nian; Zhu, Chunli; Wang, Tao; Zhang, Xi
title: The Evaluation of Sleep Disturbances for Chinese Frontline Medical Workers under the Outbreak of COVID-19
date: 2020-03-08
journal: nan
DOI: 10.1101/2020.03.06.20031278
sha: e53f5a6c4cbac340f0d97a4ba3289c30b7222dd5
doc_id: 938621
cord_uid: dtoheyo4

Background The outbreak of coronavirus disease 2019 in China remains to be a serious challenge for frontline medical workers (fMW). They are under high risk of being infected and high mental stress, which may lead to sleep disturbances, anxiety, and depression. Methods We conducted a cross-sectional study to evaluate sleep disturbances of fMW and made a comparison with non-fMW. The medical workers from multiple hospitals in Hubei Province, China, were volunteered to participate. An online questionnaire, including Pittsburgh Sleep Quality Index (PSQI), Athens Insomnia Scale (AIS), and Visual Analogue Scale (VAS), was used to evaluate sleep disturbances and mental status of fMW. Sleep disturbances were defined as PSQI>7 points or/and AIS>6 points. We compared the scores of PSQI, AIS, anxiety and depression VAS, and prevalence of sleep disturbances between fMW and non-fMW. Subgroup analysis for different gender in fMW was conducted. Findings A total of 1306 subjects (including 801 fMW and 505 non-fMW) were enrolled. Compared to non-fMW, fMW had significantly higher scores of PSQI (p＜0.0001), AIS (p＜0.0001), anxiety (p＜0.0001) and depression (p=0.0010), and higher prevalence of sleep disturbances with PSQI > 7 points (p＜0.0001) and AIS > 6 points (p＜0.0001). In subgroup analysis, compared to male fMW, female fMW had significantly higher scores of PSQI (p=0.022) and higher prevalence of sleep disturbances with PSQI > 7 points (p<0.0001). Interpretation fMW had higher prevalence of sleep disturbances and worse sleep quality than non-fMW. Female fMW were more vulnerable to having sleep disturbances than male fMW. Funding None.

As a group of enveloped RNA viruses, coronaviruses are distributed broadly among humans and other animals, and can cause multi-organs infections, mainly invade the respiratory system [1] [2] [3] . In December 2019, several pneumonia patients with cryptogenic etiology were reported in Wuhan, Hubei Province, China [4] . A novel coronavirus was identified as the arch-criminal and has established efficient human-to-human transmission. It subsequently was named as coronavirus disease 2019 (COVID-19) by the World Health Organization (WHO) [5] [6] [7] . With the unknown mighty infectivity, COVID-19 has spread rapidly, confirmed cases were reported in Wuhan, Hubei Province, other regions in China, and other countries successively [8] [9] [10] . The grim situation has attracted worldwide attention. More than 75000 cases were confirmed with COVID-19 in China, including 3000 doctors and nurses at least [11] , who have become the high-risk susceptible population to the disease. In addition to the risk of being infected with COVID-19, frontline medical workers (fMW) may have sleep disturbances, anxiety and depression when facing with a magnitude outburst public health incident.

Sleep disturbances are defined as the mental or/and physical status that trigger a series of adverse symptoms owing to abnormal amount of sleep or/and poor sleep quality, and remain to be one of the global health concerns [12, 13] . Sleep disturbances have a Province, China. The institutional ethics review boards of the participating hospitals approved this study. The study protocol was conducted in accordance with the Declaration of Helsinki. Informed consent was waived due to the cross-sectional nature of this study. All of subjects included in the study were anonymous and volunteered to participate. Subjects were divided into two groups according to the existence of directive exposure to COVID-19 patients, including fMW and non-fMW.

The inclusion criteria for this study were as follows: (a) age older than 18 years old; 

The online survey was conducted in February 2020 among medical workers from multiple hospitals in Hubei Province, with the contents encompassing basic information (age, gender, marriage, education level and etc.), epidemiological investigation, details of work, Pittsburgh Sleep Quality Index (PSQI), Athens group. In addition, we compared the prevalence of sleep disturbances in two groups, aiming to reflect the overall level of sleep quality for medical workers in different work environments.

Categorical variables were described as frequencies and percentages, and continuous variables were described as the mean ± SDs. Statistical analyses were performed using SPSS 23.0 for Windows (IBM, Somers, NY). The demographic characteristics were compared by non-parametric test for continuous variables and by Pearson's chi-square test for categorical variables between two groups. The scores of PSQI, AIS, anxiety and depression VAS were compared by ANOVA. The variables with significant differences between two groups in demographic characteristics were described as covariants and joined in the process of ANOVA. In the subgroup analysis of fMW, the scores of PSQI, AIS, anxiety and depression VAS were compared by ANOVA between male and female fMW. A P-value <0.05 was considered to indicate statistical significance in all statistical analyses. Partial correlation analysis was conducted to investigate the correlation between PSQI, AIS, anxiety and depression.

. 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 peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.03.06.20031278 doi: medRxiv preprint

A total of 1306 medical workers (801 in fMW group and 505 in non-fMW group; Table 1 . There were 68.4% of subjects married and 11.9% of subjects had high education level (Master's degree and Doctor's degree). Only 11.3% of subjects had advanced-rank in hospitals, who may present with more affluent working experience and positive attitudes toward COVID-19. In demographic characteristics, 

The detailed comparisons of scores between two groups are presented in Table 2 . The scores of PSQI, AIS, anxiety and depression VAS in fMW group were 9.3±3.8, 6.9

±4.3, 4.9±2.7, 4.1±2.5, respectively, and in non-fMW group, they were 7.5±3.7, 5.3±3.8,4.3±2.6, 3.6±2.4, respectively. Compared to non-fMW group, the fMW group had significantly higher scores of PSQI (9.3 vs 7.5, P＜0.001; Figure 2A ), AIS . 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 peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.03.06.20031278 doi: medRxiv preprint (6.9 vs 5.3, P＜0.001; Figure 2B ), anxiety (4.9 vs 4.3, P＜0.001; Figure 2C ) and depression (4.1 vs 3.6, P=0.001; Figure 2D ).

The detailed comparisons of prevalence of sleep disturbances between two groups are presented in Table 3 . There were 538/801 (67.2%) fMW and 241/505 (47.7%) non-fMW with PSQI > 7 points which indicated over 60% of fMW had poor sleep quality. Meanwhile, AIS > 6 points was observed in 414/801(51.7%) fMW and 180/505 (35.6%) non-fMW, which indicated that over half of fMW had insomnia.

Furthermore, compared to non-fMW group, the fMW group had significantly higher prevalence of sleep disturbances, according to PSQI > 7 points (67.2% vs 47.7%, P＜ 0.001; Figure 3 ) and AIS > 6 points (51.7% vs 35.6%, P＜0.001; Figure 3 ).

In the subgroups analysis, detailed comparisons of scores between male and famale fMW are presented in Table 4 . The scores of PSQI, AIS, anxiety and depression VAS in male fMW group were 8.6±4.3, 6.4±4.7, 4.6±2.7, 3.8±2.4, respectively, and in female fMW group, they were 9.4±3.8, 7.0±4.2, 5.0±2.7, 4.2±2.5, respectively.

Compared to the male fMW group, female fMW group had significantly higher score of PSQI (9.4 vs 8.6, P=0.022; Figure 4A ), while no significant differences were found in AIS (7.0 vs 6.4, P=0.108), anxiety (5.0 vs 4.6, P=0.137) and depression ( of medical residents presented with low professional performance and judgement levels after the night shifts, respectively. The long working hours could potentially increase the fatigue of medical workers and be linked to the occurrence of medical errors [36] . Meanwhile, sleep deprivation could influence the medical workers in making quick and appropriate decisions for patients, which was fatal to patient care . 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 . https://doi.org/10.1101/2020.03.06.20031278 doi: medRxiv preprint [37] . Deng et al [38] . reported that job difficulty, doctor-patient relationship, psychosomatic state, environment or events, promotion or competition and total pressure scores were related to sleep disturbances for community nurses. Tucker et al [39] . found moderate work time control for medical workers could improve the sleep quantity that frequent nigh work resulted in, and work time control had association with fewer sleep disturbances. Therefore, it is rational to believe that increased work increase the possibility of fMW being infected with COVID-19 owing to affected immune system. Therefore, it is imperative to concern on sleep disturbances of fMW, . 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 . https://doi.org/10.1101/2020.03.06.20031278 doi: medRxiv preprint aiming to maintain their healthy condition and guarantee their professional performance in the battle with COVID-19.

Our study showed that the overall scores of PSQI and AIS for fWM were significantly higher than that of non-fWM, which indicated fMW had worse sleep compared to non-fMW. There were 67.2% and 51.7% of fMW with PSQI > 7 points and AIS > 6 points, respectively, which were regarded as having sleep disturbances. Our study also demonstrated that the fWM group had significantly higher prevalence of sleep disturbances than that of non-fWM. In addition, the fWM group had significantly 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 . https://doi.org/10.1101/2020.03.06.20031278 doi: medRxiv preprint would provide evidence for further targeted interventions to improve sleep disturbances in fMW. However, with the import of supportive fMW from other regions of China, the work duration of fMW may be decreased. By comparison, the non-fMW worked in a relatively mild environment and had less possibility of being infected, thus having less sleep disturbances. Our study also found that scores of PSQI among female fMW were significantly higher than that of male fMW although other scores showed no significant difference, which indicated that female fMW had worse sleep quality than male fMW in emergent events of public health. It is in accordance with previous studies [13, 44] . In a meta-analysis, Zhang et al [45] . calculated a hazard ratio of 1.41 for female versus male toward insomnia. In general, females had inferior symptom bearing and more bodily vigilance, and the social culture encouraged females to express the indisposition more [46] , which potentially exaggerated the severity and prevalence of sleep disturbances. In addition, females tended to report more sleep problems even if having a similar degree of morning awakening compared to males [45] .

Our study has several limitations that should be noted. First, this is a cross-sectional study. All subjects were volunteered to participate in our survey, so there may be subject selection bias. Second, there are other occupations who directly expose to COVID-19 patients and experience sleep disturbances potentially, such as police and social workers, but our study merely included the medical workers. Third, our questionnaires did not contain sufficient items, such as the potential risk factors for 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. . 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. . 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 . https://doi.org/10.1101/2020.03.06.20031278 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 . https://doi.org/10.1101/2020.03.06.20031278 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 . . 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 peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.03.06.20031278 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.

(which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.03.06.20031278 doi: medRxiv preprint fMW= frontline medical workers, Non-fMW= Non-frontline medical workers.

. 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 peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.03.06.20031278 doi: medRxiv preprint 

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