Can psychiatry wards spread COVID infections

Placing no hand sanitizer on the hospitals psychiatric ward fearing that the patients would drink it; making them sleep together in communal rooms with the windows sealed shut to prevent suicide attempts, are all conditions that can be a perfect environment for the rapid spread of a potentially deadly virus.

Is there an example

This scenario was reported last month by the UK newspaper The Independent. This was happening in the psychiatric ward of South Koreas Daenam Hospital after COVID-19 struck. Eventually, the ward was put on lockdown, but soon all but two of the units 103 patients tested positive for the virus.

What is the answer

Staff at an Israeli hospital have created the "worlds first" dedicated COVID-19 unit for psychiatric inpatients.

Clinicians at Israels national hospital, Sheba Medical Center Tel HaShomer in Tel Aviv, expect that the 16-bed unit, officially opened on March 26, will prevent psychiatric inpatients with the virus, who may have trouble with social distancing, from spreading it to others on the ward.

What is the risk

In a psychiatric ward, a COVID-19 positive patient can also be psychotic, manic, cognitively impaired, or have poor judgment, thus making it difficult for that patient to keep social distancing. This can soon give rise to an entire ward of infected patients.

What were the public health issues and how were they tackled

The issue is ‘How to prevent one psychiatric patient who is hospitalized and COVID-19-positive from making everybody else sick.’

Adapting an existing psychiatric ward to one that was exclusively meant for inpatients with COVID-19 needed significant planning, coordination, and modifications to ensure the well-being of patients and staff.

The wards air conditioning system was re-engineered to separate it from the hospitals main system. A dedicated entrance for the exclusive use of infected psychiatric inpatients had to be created.

Two-way television cameras were installed in patients rooms to promote effective communication and enable therapeutic sessions and family visits. All of these modifications were completed in less than a week’s time.

Under normal circumstances, there are cameras in the public areas of the wards, but in order to respect peoples privacy, there are no cameras in their rooms.

However, in this specific ward, cameras were installed in the rooms, so that if a patient needed to be watched more closely, it could be done from a distance without exposing staff to the virus.

Protective personal equipment (PPE) and clothing for staff was tailored to the unique challenges posed by the wards patient population.

All personnel working on the ward have to put on an extra layer of PPE as well as a tear-proof robe. A strict protocol has been implemented to govern the order in which PPE is donned and doffed.

Why do now the medical students fear handling the three cult communities

They are afraid that they will not follow the medical advice about COVID-19, MDR infections and MDR-TB and will spread the infections in the community.

The Indian Ministry of Home Affairs has asked the states and Union Territories to investigate Rohingya-Tablighi links and has stated that Rohingya Muslims and their contacts may need to be screened for COVID-19.

The letter from the ministry states that it has been reported that Rohingya Muslims attended ijtemas and other religious congregations of Tablighi Jamaat and it is possible that they may have contracted COVID-19. Rohingyas living in camps in Telanganas Hyderabad had attended Tablighi Jamaat ljtema at Mewat in Haryana and had visited the Nizamuddin Markaz in New Delhi.

Who are Rohingya people

They are a stateless Indo-Aryan ethnic group, predominantly follow Islam and reside in Rakhine State, Myanmar (previously Burma).

Rohingya population is denied citizenship under the 1982 Myanmar nationality law.

They are also restricted from freedom of movement, state education and civil service jobs.

Who are Tablighi Jamaat

This is an Islamic missionary movement that focusing on exhorting Muslims and encouraging fellow members to return to practicing their religion as it was practiced during the lifetime of the Islamic prophet Muhammad, and particularly in matters of ritual, dress and personal behavior.

What is Shincheonji, Church of Jesus

The Temple of the Tabernacle of the Testimony (SCJ), commonly known as Shincheonji Church of Jesus or simply Shincheonji, is a Christian new religious movement established on 14 March, 1984 in South Korea by Lee Man-hee.

The group is known for being secretive; adherents believe that the groups founder Lee is with the returned Jesus Christ and that the Holy Bible is written in secret metaphors which only Lee can correctly interpret.

The group became the center of controversy during the 2020 coronavirus pandemic in South Korea, wherein the disease spread in Daegu. The disease spread among Shincheonjis members and thousands of others. The groups founder and senior leaders refused to get tested, citing their religious beliefs to privacy, thus causing a national outcry against the group, which prompted the Mayor of Seoul, Park Won-soon, to file a lawsuit.

CMAAO Coronavirus Facts and Myth Buster 63: Mental Health

COVID-19: Lessons learned

S: Service: same to everyone, presume every person to be COVID-positive and every surface to be coronavirus positive

E: Excellent: Anticipate (endemic, epidemic, pandemic; lock down; physical distancing, sealing, flexible to involve all segments of healthcare in emergency and watch what is happening globally)

R: Responsible: Provide the same standard of care to everyone, to the people, which you would expect for yourself

V: Value based: Team building, taking care of the healthcare providers. Treat and protect them as airlines treat their crew.  

E: Enthusiasm: Never lose hope, we shall overcome one day, with a hope for the better

Financial stress: what was the experience of mental health effects of unemployment by observing trends during the Great Recession of 2007 to 2009

For every 1% increase in unemployment in the United States, there was an approximate 1% increase in suicide, and the approximate 4% increase in unemployment during that time corresponded with a 4% hike in suicide.

Chronic stress impacts immune system, overall physical health

The pandemic can be viewed as a macroscopic chronic stressor.

Chronic stress can weaken the immune system, which should be functioning optimally during the COVID-19 pandemic. Stress can inhibit healthy functioning of the digestive system, and can result in negative effects to the circulatory system due to increased heart rate, increased blood pressure and increased risk for heart disease over time.

Which individuals with chronic medical conditions are particularly at risk for negative outcomes of elevated stress

Those with diabetes may have difficulty controlling their glucose levels. Among patients with cancer who are immunocompromised, stress has been tied to more rapid tumor growth.

Is stress linked to ethnic groups

Chronic diseases can affect certain subgroups more than others. Diabetes, heart disease and obesity have been shown to disproportionately affect people with mental illnesses and certain racial/ethnic groups, such as African Americans, in comparison with the general population.

Stress causes inflammation or inflammation causes stress

The chronic, noncommunicable conditions not only cause inflammation, but they may occur as a consequence of it.

One of the reasons why greater complications are being seen among African Americans, people of lower socioeconomic status and those with mental illness in response to COVID-19 is possibly because these individuals have an immune-dysregulated condition. Being mentally ill or having diabetes and then being challenged by the stress related to fear of the virus, of job loss or of financial insecurity further weakens the immune system. This renders these individuals more susceptible to not only viral complications if they get it, but also complications from their underlying medical conditions.

Managing stress in the era of COVID-19

Clinicians should be proactive in reaching out to patients who may have increased vulnerability at this time,  especially those who live alone.

While speaking to patients, clinicians can seek information on what worked for these patients in the past when they’ve been under high levels of stress.

Clinicians can ask patients questions such as: What are some stress management tools that were effective for you in the past? Are you using those tools now during the pandemic? If not, would you be willing to consider reengaging them, or perhaps adding some new ones to your coping toolbox?

Which techniques can be used

Mindfulness meditation strategies are among the most effective strategies.

Additionally, simple initiatives, such as taking a walk outside, listening to music from a joyful period in one’s life or watching a funny movie can help alleviate stress.

[Healio Psychiatry]

How to manage sleep problems

Encourage people to use this opportunity to their advantage and align their schedules with their natural circadian rhythms.

There may actually be some improvement in sleep durations given that most people are working from home with more time with family and less work-related stress.

While daylight has a huge impact on regulating circadian rhythms, artificial light, meal times, diet, and amount of physical activity can also have an effect. Both excessively high activity levels, such as stress and work overload, and excessively low levels, such as from depression or confinement can have a negative impact on sleep.

How common will be PTSD

The current situation also facilitates interactions between stress, sleep, anxiety, and risk of PTSD.

Those sensitive to stress-related sleep disruption have increased odds of developing chronic insomnia, which, combined with a major stressor, is a risk factor for PTSD.

About 7% of residents in Wuhan, particularly women, reported PTSD symptoms after the COVID-19 outbreak, and anxiety was reported to be the highest in those below 35 years of age and those who followed news about the disease for more than 3 hours a day.

Better sleep quality and fewer early morning awakenings were found to be protective against PTSD symptoms. The authors observed the value of physical exercise, cognitive interventions, and relaxation techniques, including meditation, for reducing stress and milder symptoms of PTSD. [Medscape]

What are the sleep recommendations

• Get up and go to bed at approximately the same times every day.
• 15-minute breaks to be scheduled during the day to manage stress and think about the situation.
• The bed should be reserved for sleep and sex only; not for working, watching TV, using the computer, or doing other activities.
• Follow your natural sleep rhythm as much as possible.
• Social media to be used as stress relief, a way to communicate with friends and family, and distraction, especially with uplifting stories or humor.
• Devices to be left out of the bedroom.
• Exposure to news about the COVID-19 pandemic to be limited.
• Exercise regularly, ideally in daylight.
• Try to stay busy and distracted, including making your home or bedroom more comfortable if possible.
• Try to obtain as much daylight during the day as possible, and keep lights dim or dark at night.
• Engage in familiar, comfortable, relaxing activities before bedtime.
• If your daily activity level is lower, eat less, and ideally at least 2 hours before going to bed.

Recommendations specifically for families:

• Child care, home maintenance, and chores to be divided between adults; ensure that the lions share does not fall on women.
• Regular sleep times to be maintained for children; spend the 30 minutes before their bedtime doing a calming, familiar activity that both the children and parents enjoy.
• Using computer, smartphones, and watching TV more than usual may be unavoidable in confinement. Try to avoid technological devices after dinner or too close to bedtime.
• Ensure that your child has daily physical activity, keep a relatively consistent schedule or routine, expose them to as much daylight or bright light as possible during the day, and limit their bed use only to sleeping, if possible. Parents should be involved in setting schedules for sleep and meal times so that kids do not get into sleep patterns that are difficult to change when school starts back.
• Limiting screen time is important, especially during nighttime.
• Reassure children if they wake up anxious at night.

[J Sleep Res. April 4, 2020.] 

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA