key: cord-314517-n1yj2zdy authors: Huang, Dayong; Shu, Wen; Li, Menglong; Ma, Juntao; Li, Ziang; Gong, JiaJian; Khattab, Nourhan M; Vermund, Sten H; Hu, Yifei title: Social media survey and web posting assessment of the COVID-19 response in China: Health worker attitudes towards preparedness and personal protective equipment shortages date: 2020-08-31 journal: Open Forum Infect Dis DOI: 10.1093/ofid/ofaa400 sha: doc_id: 314517 cord_uid: n1yj2zdy BACKGROUND: Understanding health worker awareness, attitudes, and self-confidence in the workplace can inform local and global responses towards emerging infectious threats, like COVID-19 pandemic response. Availability of accessible personal protective equipment (PPE) is vital to effective care and prevention. METHODS: We conducted a cross-sectional survey from February 24-28, 2020 to assess COVID-19 preparedness among health workers. In addition, we assessed trends from search engine web crawling and text-mining data trending over the Sina Weibo platform from January 1 to March 3, 2020. Data were abstracted on Chinese outbreak preparedness. RESULTS: In the survey, we engaged 6,350 persons, of whom 1,065 agreed to participate and after an eligibility logic check, 1,052 participated (16.6%). We accessed 412 internet posts as to PPE availability. Health workers satisfied with current preparedness to address COVID-19 were more likely to be female, to obtain knowledge about the SARS-CoV-2 outbreak from government organizations, and to consider their hospital prepared for the outbreak management. Health workers with more confidence in their abilities to respond were those with more faith in their institution’s response capacities. Elements of readiness included having airborne infection isolation room, visitor control procedures, training in precautions and PPE use. Both survey and web post assessments suggested that health workers in need were unable to reliably obtain PPE. CONCLUSION: Health workers’ self-confidence depends on perceived institutional readiness. Failure to maintain available PPE inventory for emerging infectious diseases preparedness suggests a failure to learn key lessons from the 2003-2004 SARS outbreak in China. According to the Coronavirus disease (COVID-2019) situation reports of the World Health Organization (WHO), SARS-COV-2 infections had been reported from 213 countries, territories, or international conveyances (ships) by August 8, 2020 1 . China has been classified from a level 5 country for community viral transmission, the highest level of concern 2 based on clusters of cases. WHO had urged nations to prepare for the threat of autochthonous transmission, noting that emerging cases from secondary transmission now typically lacked a direct link to the original China epicenter. The U.S. Centers for Disease Control and Preparedness (CDC) define a pandemic as a global disease outbreak (i.e., multicontinent) in its all-hazards preparedness guide 3 and pandemic infectious threats is health professional preparedness. In the WHO influenza pandemic plan in 1999, WHO urged the global community for plans to address "infectious diseases: global alert, global response" 4 . This plan was eerily prescient as to the SARS pandemic just four years later. The roles and responsibilities of the WHO and national authorities in preparing for and responding to an influenza pandemic are identical to what would be needed for other respiratory pandemic threats. Health workers are critical for building societal confidence during epidemic outbreaks. They cannot function effectively if they lack personal protective equipment (PPE), essential to ensure continuity of healthcare services during a public health emergency and to avoiding nosocomial acquisitions 5 A c c e p t e d M a n u s c r i p t 6 As of April 4, 2020, 60 Chinese health workers have died, of whom 22 (36.7%) were confirmed dead of COVID-19, according to reports by China Central Television. At least 3,387 medical staff from 476 medical institutions across the country were infected with SARS-COV-2, including 2,055 confirmed cases, 1,070 clinically diagnosed cases, and 157 suspected cases. In Hubei Province alone, 3,062 infected cases (>90% of the national total) in health workers were reported by February 24, 2020 7 (No further update was released officially since hospital burdens were eased after a large national-wide medical taskforce was dispatched to Hubei province for assistance). We sought to study health worker self-perception of preparedness and PPE availability in 2020, over two decades after the WHO call for pandemic influenza readiness. Our mixed methods study was a two-part effort consisting of: (1) an online cross-sectional survey using an online electronic questionnaire and (2) a mining of web text via data crawling of PPE-related postings (Fig 1) . Data crawling is a technique for data extraction from the Internet using a crawling agent (automated script) that helps gather publicly available data in very large quantities. Our survey was based on the WHO and CDC preparedness checklists and we targeted licenced health workers, evaluating awareness of, and confidence in COVID-19 preparedness and response at their institutions. We also reviewed policy changes on provision of PPE in China related to the 2019-2020 SARS-CoV-2 outbreak. A c c e p t e d M a n u s c r i p t 7 Our survey targeted health workers based in hospitals, including physicians, nurses, and others. Eligible participants were licensed health workers in practice; given our Hubei province focus, this including workers at the front-line of care provision in the midst of the COVID-19 crisis. While we did not indicated exclusion criteria in the recruitment poster (supplemental Fig 1) , we specified our research aims regarding self-perception of health worker preparedness. Online consent was obtained for participation. Participants were recruited using two methods. The first was an online advertisement on a The second means of recruitment was engagement via WeChat "moments sharing". WeChat is a comprehensive package of online services, equivalent to combining Apps such as Facebook  , WhatsApp  , and PayPal  . Eligible recruited persons providing consent were given a self-administered structured questionnaire online using https://www.wjx.cn/. This "wjx" is similar to SurveyMonkey  and is more popular and accessible in China. We developed a poster with a QR code to link people to the questionnaire (Suppl. Fig 1) . Both the Physician Service App and the WeChat moments sharing methods promoted the poster A c c e p t e d M a n u s c r i p t 8 and encouraged interested health workers to identify the QR code and enter the online survey system. The first page of the questionnaire assessed eligibility and obtained informed consent for those who were eligible. No incentive was provided for survey participation. We studied three main outcome indicators using 5 or 3- Text mining of the Weibo announcement searched (in Chinese) for "(help OR support OR donate) AND PPE" . Weibo is a Twitter  -like social media platform in China. People share social, cultural, and historical insights or comments on trending topics via the platform. We crawled text data or scripts of the video of needed PPE including "求助" (help) or "防护服" (gown)or "口罩" (facemask) from https://weibo.com/ from Jan 1, 2020 through March 3rd, 2020 using Python TM 3.8.2. After manually verifying and cleaning the raw data, we The survey data were exported into Microsoft Excel ® and then manually labelled with the level of the capability of the hospital according to the 3-tier category in China. Through dynamic IP address and the name of the local hospital, we identified the geo-location of the participants and generated two variables of the location as "city" and "province" for each participant. In the case of a conflict between IP address and hospital, we chose the affiliated hospital for location classification. Completed databases were analysed after data cleaning using Statistical Analysis System  (V.9.4; SAS Institute Inc, Cary, NC, USA). We used univariate and multivariable logistic regression analysis to identify the association between a respondent's current confidence in coping with COVID-19 suspected/confirmed cases and his/her sociodemographic characteristics. Crude and adjusted odds ratios (cOR and aOR) with 95% confidence interval (95%CI) were calculated for the association of the covariates with the outcome (self-confidence). The variables with p value of <0.05 in univariate analysis were entered into the multivariable backward regression models and only variables with twosided p value of <0.05 or less were considered statistically significant in the final model. A c c e p t e d M a n u s c r i p t 10 The study was approved by Capital Medical University Ethics Review Board (2020SY004). The study protocol, contents, and procedure were explained before survey inception. Online consent was obtained for participation. Non-identifiable data from the App was collected or analysed per the study protocol. The web-based questionnaire was uploaded February 24, 2020 and taken offline on Fig 2b) . Doctors accounted for 75.8% of the respondents, nurses representing 17.3%, and others 6.9%. Fewer than half (48%) of participants were satisfied with the protective equipment in the hospital to cope with the COVID-19 epidemic, and 6.4% of respondents were very dissatisfied. Nearly three-quarters (73%) of health workers expressed selfconfidence in coping with persons under investigation (PUI) or known patients. About half (53%) of the participants expressed confidence in institutional preparedness and its ability to respond to EIDs in the future (Table 1) . A c c e p t e d M a n u s c r i p t 11 There were 412 posts of PPE request announcements from our Weibo crawl during January 1 to March 3, 2020. For 386 posts, we were able to do manual city-labelling, narrowing the focus of the request for PPE and mapping respondents' locations (Fig 2) . Weibo posts calling for help or donations of PPE, including gowns, facemasks, and goggles, increased sharply from January 23 to January 25, 2020 and the number of cities that posted requests for urgent help for medical supplies online increased drastically, and then levelled After the lockdown of the city of Wuhan, policy guidance was gradually put into place. Health workers who were infected were seen in the early stages of the epidemic, correlating with the time of acute shortage of PPE. After centralized management and emergency response protocols and the action of PPE manufacturers to accelerate production and supply mobilization to the Hubei province epicenter, the number of health workers being infected decreased significantly (Fig 3) . A c c e p t e d M a n u s c r i p t 12 Suppl. Table 1 presents predictors of health workers' satisfaction with current readiness of PPE in their hospitals during the outbreak. Multivariable analysis suggested that health workers who were more satisfied with the readiness of the affiliated hospitals were more likely to be female (aOR=1.30, 95% CI: 1.03-1.63), obtain knowledge /information of the SARS-CoV-2 outbreak from government sources (aOR= 1.36, 95% CI: 1.03-1.81), have airborne infection isolation rooms in their hospital (aOR= 2.15, 95% CI: 1.69-2.74), and to think their hospital is prepared for the outbreak (aOR= 4.28, 95% CI: 3.14-5.83). Suppl. Table 2 presents predictors with a sense of confidence in treating patients and confidence in current institutional readiness during the outbreak. Those who tended to have higher current confidence to deal with suspected patients were more likely to be male health self-discipline to exercise in order to increase immunity (5%), and rotating the shift times since wearing PPE accelerated a sense of exhaustion in the medical workplace (3%). Over half of them recommended compulsory training on self-protection standards. Some respondents suggested the need for attention to gender-related vulnerability in crises. One example was for female health workers to be allowed to take breaks during their menstruation due to inconvenience with gowning and consequent potential of increasing infection risks. Over 10% of the respondents complained about an amateurish style of hospital leadership, for instance, exhibiting managerial incompetent to achieve effective responses as well as exhibiting a lack of health care knowledge and professionalism (Suppl. preparedness of their hospitals than in their personal readiness. Since hospital level preparedness requirements are intensive and complex to battle outbreaks, our finding echoed an Ebola virus preparedness report from the U.S. 11 Compulsory training on precautions and the application of universal standard guidelines, including PPE use, can reduce occupational infection and increase confidence during a crisis 9, 12 . Health emergency responders should consider integrating grass-root level simulation training for staff (primary and undetermined hospitals, clinics) to increase the capacity and readiness for patient management 13 . We also found that health workers had more trust in the source of information when it was from the government than from other channels. This may be true in China, but could plausibly be the opposite in other nations. Chinese health authorities' timely disclosure of epidemic information likely increased a sense of security through viable up-to-date information in late January 10, 14, 15 . Better hospital infrastructure, worker satisfaction with PPE, and a worker's current sense of confidence in the hospital's current readiness seem to increase self-confidence of health professional staff in addressing EIDs 16 . Outbreaks and epidemics mean that hospitals and frontline care facilities need products in unprecedented quantities 17 . Alongside the significant spike in product demand, health care workers can experience fear and panic, devastating the confidence of the public and health workers alike. This occurred when PPE distributors and manufacturers were unable to fill early orders for the SARS-CoV-19 programs 5 . Hospitals and governments must address the needs for surging supply and stock via tiered advanced planning to cope with different epidemic scenarios 18, 19 . This phenomenon can also be seen in A c c e p t e d M a n u s c r i p t 17 Study strengths were the ability to draw conclusions from mixed methods results. That we could do the study in such proximity to the epidemic's geometric rise ensures the freshness of opinions of our respondents, minimizing recall bias. Our study has some limitations. Data crawling text information was gathered retrospectively. It may underestimate the actual quantity of postings asking for PPE help since some information that was shared by the institutions may have been taken down when their needs were met. Some information over the internet (such as criticisms of local responses) are more likely to be removed than other responses, making the current data an under-estimate of gaps in preparedness. Changes in the trend of numbers may reflect either true product shortages or difficulties in supply chains over time. Our survey was a convenience web-based sample with a comparatively low response rate, limiting generalizability. However, this method was the only feasible way to avoid intra-person contact in data gathering during the pandemic crisis in China. Since our survey was conducted after the PPE supply need was almost met after extreme scarcity, the satisfaction rate of the PPE supply may have been an overestimate. Ensuring PPE supply for health workers is an essential inventory component for effective health emergency response, and PPE should be an integrated element in all-hazards emergency preparedness procedures. PPE availability increases a sense of confidence among health workers and reduces nosocomial infection. Tiered management, reasonable rotation, specified inventory of PPE for stockpile, and inventories that are ready-for-use for health workers are all vivid lessons from China for consideration by other global infection control fighters. WHO. Coronavirus disease (COVID-19) Situation Report -201 COVID-19). WHO. 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