key: cord-0799183-7a1rrtzk
authors: Qiu, Dan; Li, Yilu; Li, Ling; He, Jun; Ouyang, Feiyun; Xiao, Shuiyuan
title: Infectious Disease Outbreak and Post-Traumatic Stress Symptoms: A Systematic Review and Meta-Analysis
date: 2021-08-05
journal: Front Psychol
DOI: 10.3389/fpsyg.2021.668784
sha: c0c0ba70363dd6da866419cc1929e50abd4d620b
doc_id: 799183
cord_uid: 7a1rrtzk

Background: As one of the most widely researched consequence of traumatic events, the prevalence of post-traumatic stress symptoms (PTSS) among people exposed to the trauma resulting from infectious disease outbreak varies greatly across studies. This review aimed at examining the pooled prevalence of PTSS among people exposed to the trauma resulting from infectious disease outbreak, summarizing the possible causes of the inconsistencies in the current estimates. Methods: Systematic searches of databases were conducted for literature published on PubMed, EMBASE, Web of Science, the Cochrane Library, PsycArticles, and Chinese National Knowledge Infrastructure (CNKI) until 14 October 2020. Statistical analyses were performed using R software (registration number: CRD42020182366). Results: About 106 studies were included. The results showed that the pooled prevalence of PTSS among the general population exposed to the trauma resulting from infectious disease outbreak was 24.20% (95% CI: 18.54–30.53%), the pooled prevalence of PTSS among healthcare workers was 24.35% (95% CI: 18.38–1.51%), the pooled prevalence of PTSS among patients with infectious disease was 28.83% (95% CI: 18.53–44.86%), and the pooled prevalence of PTSS among suspected cases of infectious disease was 25.04% (95% CI: 18.05–34.73%). Mortality rate was a significant contributor to heterogeneity. Conclusions: Evidence suggests that PTSS were very common among people exposed to the trauma resulting from infectious disease outbreak. Health policymakers should consider both short-term and long-term preventive strategy of PTSS.

Infectious disease poses a serious threat to public health. Over the past two decades, novel viruses continuing to emerge, the number of reported outbreaks of highly pathogenic or highly transmitted infectious diseases has increased, such as severe acute respiratory syndrome (SARS) in 2003 (SARS) in , 2009 influenza A (H1N1) in 2009, and Ebola virus disease (Ebola) in 2014 (Houlihan and Whitworth, 2019) . At the end of 2019, a new type of infectious disease emerged, which is known as coronavirus disease 2019 . As of December 10, 2020, over 66.2 million cases of COVID-19 and about 1.5 million deaths have been reported to the WHO (WHO, 2020) . The outbreak of infectious disease can spread rapidly, causing enormous losses to individual health, national economy, and social well-being (Steele et al., 2016) .

The psychological effects of infectious disease outbreak can be deleterious and far-reaching. Previous research indicates high prevalence rates of clinically relevant post-traumatic stress symptoms (PTSS) among people exposed to the trauma resulting from infectious disease outbreak (such as the outbreak of SARS; Gardner and Moallef, 2015) . Patients with post-traumatic stress disorder (PTSD)-related symptoms live under the shadow of past trauma. According to the Diagnostic and Statistics of Mental Disorders, the fifth edition (DSM-5), the clinical features of PTSD include persistent intrusion symptoms, persistent avoidance of stimuli, negative alterations in cognition or mood, and marked alterations in arousal and reactivity, all of which are related to traumatic events (Association, 2013) . PTSS could cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Greene et al., 2016) . When an infectious disease breaks out, people may experience many types of psychological trauma, such as directly suffering from the symptoms and traumatic treatment, witness of suffering, and struggling and dying of patients (Fiorillo and Gorwood, 2020) . Additionally, individuals may experience the fear of realistic or unrealistic of infection, social isolation, exclusion, and stigmatization, as patients, care and help providers, or even the general public (Kisely et al., 2020; Morganstein and Ursano, 2020) . As one of the most widely researched consequence of traumatic events, the prevalence of PTSS among people exposed to the trauma resulting from infectious disease outbreak varies greatly across studies (Lancee et al., 2008; Jung et al., 2020) . In order to provide more reliable prevention, it is necessary to determine a more accurate estimation of the prevalence of PTSS among people exposed to the trauma resulting from infectious disease outbreak and to explore the possible causes of the inconsistencies in the current estimates.

Currently, control of the epidemic of COVID-19 is still the dominant task of the whole world, millions of people are scared and even panic of the possible loss of health, life, and wealth (Dutheil et al., 2020) . A few epidemic studies reported that experience and witness of the suffering related to COVID-19 resulted in a high prevalence of PTSD-related symptoms (Kisely et al., 2020; Rogers et al., 2020) . Although it is too early to predict how many people worldwide will be infected with the virus, it is believed that the numbers of case and death will continue to increase in the following months. Some psychologists draw attention toward PTSD as the second tsunami of the COVID-19 pandemic (Dutheil et al., 2020) . For taking effective measures to reduce the psychological sequelae caused by COVID-19 across the world, understanding how infectious disease outbreak cause PTSD and who might be vulnerable are essential. This review aimed at examining the pooled prevalence of PTSS among people exposed to the trauma resulting from infectious disease outbreak (including infectious diseases over the past 20 years and COVID-19), summarizing the possible causes of the inconsistencies in the current estimates, and examining potentially vulnerable populations, try to provide a reference for COVID-19 and possible outbreak of infectious diseases in the future.

This review was reported in accordance with the PRISMA guideline and the Meta-analyses Of Observational Studies in Epidemiology (MOOSE) guidelines (Stroup et al., 2000; Moher et al., 2009) .The protocol of this review is registered in the International Prospective Register of Systematic Reviews (registration number: CRD42020182366). See Supplementary Material for the details.

Search Strategy rate, percentage of male participants, average age of participants, instruments used to identify PTSS, prevalence of PTSS, and quality score of the included studies. Any discrepancies that emerged in these procedures were discussed and resolved by involving a third reviewer (SYX).

Two independent reviewers (JH and FYOY) used the established guidelines, the Loney criteria, to evaluate the methodological quality of the included studies, which has been widely used to evaluate observational studies (Loney et al., 1998; Sanderson et al., 2007) . The included papers were scored according to eight criteria, such as definition of participants, study design, sampling method, response rate, sample size, and appropriateness of measurement and analysis. The scores range from 0 to 8, with a score of 0-3 as low quality, 4-6 as moderate, and 7-8 as high (Qiu et al., 2020) . See Supplementary Table 3 for details on the quality assessment.

When data were available for three or more studies, the prevalence was combined. When there were 10 or more studies, the quantitative subgroup analysis was conducted. All the statistical analyses were performed using the "meta" (4.12-0) and "metafor" package (2.4-0) of R version 4.0.0. Betweenstudy heterogeneity was evaluated by Cochran's Q-test and quantified by the I 2 statistic, with values 50% or more indicating possible heterogeneity (Higgins et al., 2003; Ades et al., 2005) . The pooled prevalence of PTSS was combined using the Logit transformation method or Log transformation method by a random effects model if significant heterogeneity was observed across studies (when p < 0.05, I 2 > 50%). If more than one dataset was reported for the same group of participants, the outcomes that were assessed at the baseline were used. In order to compare the prevalence from different studies, the subgroup meta-analysis was conducted. Because the subgroup analyses should be interpreted with caution (Jike et al., 2018) , we planned a priori to limit our subgroup analyses to a small number of baseline characteristics including area, sample size, type of disease, mortality rate of disease, survey time after the outbreak, gender, age, assessment tool, and quality score. The difference between subgroups was examined using the Cochran's Q chi-square tests. Mixed-model meta-regression analyses were performed by using the Freeman-Tukey double arcsine method to explore potential moderators on the heterogeneity. Publication bias was investigated by Egger's test. To evaluate the consistency of the results, sensitivity analysis was performed by removing each study individually. All the statistical tests were two-sided, with a significance threshold of p < 0.05.

As shown in Figure 1 , a total of 6,612 references were identified. Among them, 2,953 duplicates were removed. By screening titles and abstracts, 3,019 irrelevant articles were excluded. A total of 288 potentially relevant full-text articles were independently assessed based on the selection criteria. Further, 182 studies were excluded because of the following reasons: duplicate articles or results (n = 15), review (n = 1), did not provide data on PTSS (n = 114), not infectious disease (n = 44), unable to locate full text (n = 7), and not in English or Chinese (n = 1). Finally, 106 eligible studies were included in this review. See Figure 1 for the details.

One hundred and six papers met the inclusion criteria. Of the included studies, 78 were of COVID-19 (Alkhamees et al., 2020; Barbato and Thomas, 2020; Blekas et al., 2020; Bo et al., 2020; Caillet et al., 2020; Cardel et al., 2020; Castelli et al., 2020; Chang and Park, 2020; Chen B. et al., 2020; Chew et al., 2020; Chi et al., 2020; Civantos et al., 2020a,b; Cortes-Alvarez et al., 2020; Di Tella et al., 2020; Dobson et al., 2020; El-Zoghby et al., 2020; Fekih-Romdhane et al., 2020; Forte et al., 2020; Giusti et al., 2020; Gonzalez Ramirez et al., 2020; Gonzalez-Sanguino et al., 2020; Guo et al., 2020; Hao et al., 2020; Huang et al., 2020; Karatzias et al., 2020; Lahav, 2020; Lai et al., 2020; Lange et al., 2020; Le et al., 2020; Leng, 2020; Leng et al., 2020; Li, 2020; Liang S. W. et al., 2020; Li et al., 2020,a,b; Lijun et al., 2020; Liu C. H. et al., 2020; Liu N. et al., 2020; Li X. C. et al., 2020; Luceno-Moreno et al., 2020; Ma et al., 2020; Nie et al., 2020; Qi et al., 2020; Riello et al., 2020; Rodriguez-Rey et al., 2020; Rossi et al., 2020a,b; Seyahi et al., 2020; Sherman et al., 2020; Si et al., 2020; Song et al., 2020; Tan et al., 2020; Tang et al., 2020; Tee et al., 2020; Traunmuller et al., 2020; Varshney et al., 2020; Wang et al., 2020; Wesemann et al., 2020; Xie et al., 2020; Yin et al., 2020; Yuan et al., 2020; Zhang and Ma, 2020a,b; Zhang C. et al., 2020; Zhao et al., 2020; Zhou et al., 2020) (Alkhamees et al., 2020; Barbato and Thomas, 2020; Blekas et al., 2020; Bo et al., 2020; Caillet et al., 2020; Cardel et al., 2020; Castelli et al., 2020; Chang and Park, 2020; Chen B. et al., 2020; Chew et al., 2020; Chi et al., 2020; Civantos et al., 2020a,b; Cortes-Alvarez et al., 2020; Di Tella et al., 2020; Dobson et al., 2020; El-Zoghby et al., 2020; Fekih-Romdhane et al., 2020; Forte et al., 2020; Giusti et al., 2020; Gonzalez Ramirez et al., 2020; Gonzalez-Sanguino et al., 2020; Guo et al., 2020; Karatzias et al., 2020; Lahav, 2020; Lange et al., 2020; Le et al., 2020; Leng, 2020; Leng et al., 2020; Li, 2020; Liang S. W. et al., 2020; Li et al., 2020a,b; Lijun et al., 2020; Liu C. H. et al., 2020; Li X. C. et al., 2020; Luceno-Moreno et al., 2020; Ma et al., 2020; Nie et al., 2020; Qi et al., 2020; Riello et al., 2020; Rodriguez-Rey et al., 2020; Rossi et al., 2020a,b; Seyahi et al., 2020; Sherman et al., 2020; Si et al., 2020; Song et al., 2020; Tan et al., 2020; Tee et al., 2020; Traunmuller et al., 2020; Varshney et al., 2020; Wesemann et al., 2020; Xie et al., 2020; Yuan et al., 2020; Zhang and Ma, 2020a,b; Zhang C. et al., 2020; Zhao et al., 2020; Zhou et al., 2020) , two of Middle East Respiratory Syndrome (MERS) (Lee et al., 2018; Jung et al., 2020) , one of Ebola virus disease (Jalloh et al., 2018) , one of H7N9 (Tang et al., 2017) , two of H1N1 (Xu et al., 2011; Luyt et al., 2012) , and the remaining 22 of SARS (Chan and Huak, 2004; Fang et al., 2004; Hawryluck et al., 2004; Sin and Huak, 2004; Chen et al., 2005; Tie-ying et al., 2005; Wu et al., 2005 Wu et al., , 2009 Yong et al., 2005; Hongsheng et al., 2006; Kwek et al., 2006; Lee et al., 2006; Maunder et al., 2006; Zhongguo et al., 2006; Laiqi et al., 2007; Lin et al., 2007; Su et al., 2007; Lancee et al., 2008; Reynolds et al., 2008; Hong et al., 2009; Mak et al., 2010; Sim et al., 2010) . Six papers were in Chinese, and the remainder in English. Of these, 93 were cross-sectional studies, nine were longitudinal designs, and four were case control studies. Most of the included studies were from Asia, such as China, Singapore, and South Korea. See Table 1 for the details. From the 106 papers, five (4.72%) studies were rated as high quality, 93 (87.73%) were rated as moderate, and eight (7.55%) were rated as low quality. Details of the methodological quality assessments of all 106 studies are showed in Supplementary Table 3 .

There were 51 studies reported the prevalence of PTSS among the general population. The forest plot in Figure 2 depicts the details. A total of 78,459 people exposed to the trauma resulting from an epidemic of infectious disease were identified in the 51 articles, of which 25,826 were reported with PTSS. The random effects model was used to determine the pooled prevalence (I 2 = 99.70%, p < 0.001), the pooled prevalence of PTSS among people exposed to the trauma resulting from infectious disease outbreak was 24.20%, with a 95% CI of 18.54-30.53%.

The details of subgroup analyses are presented in Table 2 . There were no significant differences in the prevalence of PTSS between age and gender (Q = 0.08 and 0.16, p > 0.05). Significant difference in the prevalence of PTSS between different types of disease was observed, the pooled prevalence of PTSS among people influenced by COVID-19 was higher than that for people influenced by SARS, Ebola and H1N1 (26.75 vs. 16.42 vs. 15.99 vs. 2.03%; Q = 117.12, p < 0.05). In addition, a higher mortality rate is associated with a lower prevalence of PTSS (24.39 vs. 15.99%; Q = 8.26, p < 0.05). The pooled prevalence of PTSS among people in the Eastern Mediterranean region was higher than people in the Western Pacific region, the Southeast Asia region, the America region, the European region, and the Africa region (37.74 vs. 33.23 vs. 29.25 vs. 24.00 vs. 20.78 vs. 15.99%; Q = 114.16, p < 0.05). Furthermore, there were significant differences in the prevalence of PTSS between different survey time after the outbreak; closer survey time to the point of infectious disease outbreak was associated with a higher prevalence of PTSS (25.96 vs. 5.95%; Q = 7.49, p < 0.05). There were significant differences in the prevalence of PTSS between studies used different assessment tools (24.44 vs. 14.00%; Q = 12.18, p < 0.05). In addition, significant difference in the prevalence of PTSS between studies with different quality scores was observed, articles with the highest quality scores showed a high prevalence (12.57 vs. 12.41 vs. 25.86%; Q = 19.00, p < 0.05). A multivariate meta-regression was carried out to explore the origin of heterogeneity accounted for by the variables, such as type of disease and survey time after the outbreak. However, no significant contributor was found. See Table 5 for the details.

The results of the Egger's test showed that publication bias was not found in this study (t = −2.425, p = 0.208). When each study was excluded one by one, the recalculated combined results did not change significantly. The pooled prevalence of PTSS ranged from 23.29% (95% CI: 17.91-29.70%) to 25.13% (95% CI: 19.43-31.85%), and the I 2 statistic varied from 99.70% to 99.80%. The results indicate that no individual study significantly influenced the overall results.

A total of 41 studies reported the prevalence of PTSS among the healthcare workers. The forest plot in Figure 3 depicts the details. A total of 38,250 healthcare workers exposed to the trauma resulting from an epidemic of infectious disease were identified in the 41 articles, of which 9,071 were reported with PTSS. The random effects model was used to determine the pooled prevalence (I 2 = 99.40%, p < 0.001), the pooled prevalence of PTSS among healthcare workers exposed to the trauma resulting from infectious disease outbreak was 24.35%, with a 95% CI of 18.38-31.51%.

The details of subgroup analyses are presented in Table 3 . There were no significant differences in the prevalence of PTSS between age, gender, mortality rate of disease, sample size, and quality score (Q = 0.21, 0.19, 3.78, 2.54, and 4.65, p > 0.05). Significant difference in the prevalence of PTSS between different types of disease was observed, and the pooled prevalence of PTSS among people influenced by MERS was higher than that for the people influenced by COVID-19, H7N9, and SARS (52.77 vs. 29.64 vs. 20.59 vs. 11.80%; Q = 351.95, p < 0.05). In addition, 

A total of 15 studies reported the prevalence of PTSS among the patients. The forest plot in Figure 4 depicts the details. A total of 2,666 patients with infectious disease were identified in the 15 articles, of which 1,125 were reported with PTSS. The random effects model was used to determine the pooled prevalence (I 2 = 98.60%, p < 0.001), and the pooled prevalence of PTSS among patients with infectious disease was 28.83%, with a 95% CI of 18.53-44.86%.

The details of subgroup analyses are presented in Table 4 . There were no significant differences in the prevalence of PTSS between age, gender, type of disease, region, survey time after outbreak, diagnosis tool, sample size, and quality score (p > 0.05). A significant difference in the prevalence of PTSS between studies with different quality scores was observed (5.64 vs. 35.45 vs. 9.79%; Q = 31.65, p < 0.05). A multivariate meta-regression was carried out to explore the origin of heterogeneity accounted for by the variables, such as type of disease and survey time after the outbreak. However, no significant contributor was found. See Table 5 for the details.

The results of the Egger's test showed that publication bias was not found in this study (t = −6.138, p = 3.553). When each study was excluded one by one, the recalculated combined results did not change significantly. The pooled prevalence of PTSS ranged from 23.22% (95% CI: 17.69-29.84%) to 32.23% (95% CI: 20.75-50.05%), and the I 2 statistic varied from 95.40 to 98.7%. The results indicate that no individual study significantly influenced the overall results.

A total of three studies reported the prevalence of PTSS among the suspected cases. The forest plot in Figure 5 depicts the details. A total of 525 suspected cases of infectious disease exposed to the trauma resulting from an epidemic of infectious disease were identified in the three articles, of which 139 were reported with PTSS. The random effects model was used to determine the pooled prevalence (I 2 = 74.50%, p < 0.001), the pooled prevalence of PTSS among suspected cases exposed to the trauma resulting from infectious disease outbreak was 25.04%, with a 95% CI of 18.05-34.73%.

This review has highlighted the importance of considering the psychological impacts of people exposed to the trauma resulting from infectious disease outbreak. The results showed that the pooled prevalence of PTSS among the general population was 24.20% (95% CI: 18.54-30.53%), the pooled prevalence of PTSS among the healthcare workers was 24.35% (95% CI: 18.38-31.51%), the pooled prevalence of PTSS among patients with infectious disease was 28.83% (95% CI: 18.53-44.86%), and the pooled prevalence of PTSS among the suspected cases of infectious disease was 25.04% (95% CI: 18.05-34.73%), and several factors including type of disease, mortality rate of disease, region, survey time after outbreak, assessment tool, sample size, and quality score were associated with PTSS. Mortality rate of disease was a significant moderator for heterogeneity. Further research is needed to identify effective strategies for preventing and treating PTSS among people exposed to the trauma resulting from infectious disease outbreak.

The pooled prevalence of PTSS among different population exposed to the trauma resulting from infectious disease outbreak in this study ranged from 24.20 to 28.83%, which was higher than flood survivors (15.74%) and hurricane survivors (Liu et al., 2017; Wang et al., 2019) , but similar to earthquake survivors (Dai et al., 2016) and civilian war survivors (23.66-26.00%) (Morina et al., 2018) . Compared with infectious diseases, some natural disasters, such as flood and hurricane, can be predicted, whereas earthquakes and infectious disease were often happened suddenly and without a warning and pose a huge threat to health and property of people in a short period of time (Dai et al., 2016) . Therefore, earthquakes might have caused more damage to mental health of people. Relative to natural disasters, wars often last longer, and survivors directly exposed to trauma continuously (Morina et al., 2018) . Furthermore, the pooled prevalence of PTSS among patients with infectious disease was much higher than healthcare workers, the general population, and suspected cases of infectious diseases, which were consistent with previous studies (Neria et al., 2008) . The possible reason is that patients with infectious disease experience higher level of severity of disaster exposure. Patients often directly suffer from the symptoms and traumatic treatment (such as dyspnea, respiratory failure, alteration of conscious states, and tracheotomy), and after being cured, they were more vulnerable to social discrimination than other groups (Neria et al., 2008) . The pooled prevalence of PTSS in different types of diseases was different, and different mortality rates of those infectious diseases also affect the prevalence of PTSS. Among the healthcare workers, mortality rate of infectious diseases was a significant moderator for heterogeneity, higher mortality rate was associated with a higher prevalence of PTSS. Previous studies have shown that when the mortality rate of infectious diseases is high, the impact on mental health of people may be greater (Spoorthy et al., 2020) . Therefore, we think the mortality rate of these infectious diseases should be considered when formulating psychological interventions for people influenced by infectious diseases. In addition, the pooled prevalence of PTSS is relatively high in Europe and the Americas, but relatively low in Asia and Africa. The possible reason is that the epidemic situation is more serious in the first two places (WHO, 2020) . In addition, the pooled prevalence of PTSS assessed in different time points was different. PTSS among the general population and the healthcare workers were higher in the immediate aftermath of the infectious disease outbreak (0-6 months), which was in line with other studies (Heron-Delaney et al., 2013; Dai et al., 2016; Righy et al., 2019;  Benfante et al., 2020) . However, in patients with infectious disease, no significant difference was found, and the prevalence of PTSS among patients was still high even after 6 months. This difference in the prevalence estimates among different population may be explained by the fact that patients are exposed to greater trauma than other population, they need more time to recover . Furthermore, we found that the pooled prevalence of PTSS among healthcare workers and the general population identified by screening tools was significantly higher than that identified by diagnostic tools, which was consistent with previous researches (Edmondson et al., 2013) . It is reported that studies with poor methodological quality or small sample size generally yielded more extreme prevalence estimates (Mata et al., 2015) , the current study showed similar results. However, after controlling for other factors, the results of meta-regression showed that the influence of methodological quality and sample size on the prevalence of PTSS is no longer significant. Hence, the results for quality score and sample size in the subgroup analyses require further clarification.

Epidemiological studies have demonstrated a rather high prevalence of mental health problems among different population after an epidemic of infectious disease (Catalan et al., 2011; Tucci et al., 2017) . While most of these mental health problems will fade out after the epidemic, symptoms of PTSD may last for a prolonged time and result in severe distress and disability (Vyas et al., 2016) . In terms of applicability to COVID-19, evidence suggests that the symptoms of PTSD were very common and persist in patients with infectious disease even higher after 6 months (Hong et al., 2009 ). Thus, healthcare policies need to take into account both short-term and long-term preventive strategies of PTSD. The information available suggests that the prevalence of PTSS is higher among patients with infectious disease, lower among suspected cases, related workers, and yet even lower in the general population. These three types of samples studied are likely to represent different levels of severity of disaster exposure, with different levels of the PTSS prevalence (Neria et al., 2008) . However, there is little doubt that there is a dose-response relationship between the degree of trauma and the mental health burden of disasters (Neria et al., 2008) . This relation may not necessarily mean that the principal mental health burden of people exposed to the trauma resulting from infectious disease outbreak is among those who were most directly affected by the disease (Galea and Resnick, 2005) . It will be important to establish whether indirect exposure to a trauma during a COVID-19 pandemic was correlated with higher risk of PTSS. In addition, it is necessary to assess the relation between exposure to multiple traumas and risk of PTSS in the future. Additionally, the mortality rate of these infectious diseases should be considered when formulating psychological interventions for people influenced by infectious diseases. Lastly, we think a large multicenter prospective study using a single validated measure of PTSS and measuring possible confounding factors in randomly selected participants is needed in the future, which would provide a more accurate estimate of PTSS among people influenced by infectious diseases.

First, although subgroup analyses and meta-regression analyses were conducted to control many moderating factors for the pooled prevalence of PTSS, heterogeneity was still retained in this review. It is reported that heterogeneity is difficult to avoid in meta-analysis of epidemiological surveys (Winsper et al., 2013) , suggesting the need for caution when drawing inferences about estimates of PTSS in post-disaster research.

In addition, the follow-up time varies greatly among the included longitudinal studies, which hinder comparability. Additionally, although our study included relevant studies across 30 countries, more than half of the eligible studies were from upper-high income countries. Prevalence studies were scarce for many countries, especially for low-income countries. Considering the inconsistency of the healthcare environment and socioeconomic status across the world, more prevalence studies in low-income countries are needed to understand the panorama of PTSS among people influenced by infectious diseases. Lastly, we noticed that most of the included studies were used screening tools to assess PTSS, only 5.71% of studies used diagnostic tools. It is possible that the pooled prevalence of PTSS caused by infectious diseases was overestimated in this review. Thus, we think ongoing surveillance is essential.

Evidence suggests that PTSS were very common among people exposed to the trauma resulting from infectious disease outbreak, and the pooled prevalence among different population ranged from 24.20 to 28.83%. Several factors, including type of disease, mortality rate of disease, region, survey time after outbreak, assessment tool, sample size, and quality score, were associated with PTSS. Mortality rate of disease was a significant moderator for heterogeneity. Further research is needed to identify effective strategies for preventing and treating PTSS among people exposed to the trauma resulting from infectious diseases outbreak.

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author/s.

DQ, SX, and YL contributed to the design of the study. DQ and YL screened the text. DQ and LL extracted and analyzed the data. JH and FO conducted the quality assessment. DQ wrote the first draft of the manuscript with input from SX. All authors approved the final manuscript.

This research was supported by the Ministry of Science and Technology of China (Grant No.: 2016YFC0900802). The funding agency did not take part in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg. 2021.668784/full#supplementary-material

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Psychological impact on women health workers involved in COVID-19 outbreak in Wuhan: a cross-sectional study

Psychosocial and coping responses toward 2019 coronavirus diseases (COVID-19): a cross-sectional study within the Chinese general population

Factors associated with mental health results among workers with income losses exposed to COVID-19 in China

Factors associated with the psychological well-being among front-line nurses exposed to COVID-2019 in China: a predictive study

Insomnia and psychological reactions during the COVID-19 outbreak in China

Psychological distress among health professional students during the COVID-19 outbreak

The effect of COVID-19 on youth mental health

The psychological impact of the COVID-19 epidemic on Guangdong College students: the difference between seeking and not seeking psychological help

A study on posttraumatic stress reaction to the first-line medical staffs against COVID-19

The psychological effect of severe acute respiratory syndrome on emergency department staff

Factors associated with depression, anxiety, and PTSD symptomatology during the COVID-19 pandemic: clinical implications for U.S. young adult mental health

Risk factors associated with mental illness in hospital discharged patients infected with COVID-19 in Wuhan

Association of DSM-IV posttraumatic stress disorder with traumatic experience type and history in the world health organization world mental health surveys

Prevalence and predictors of PTSS during COVID-19 outbreak in China hardest-hit areas: gender differences matter

Investigation of mental health status of medical stuff from Hainan who aided Hubei province to fight against COVID-19

Investigation on the psychological stress of nursing staff during the novel coronavirus pneumonia epidemic and analysis of related factors

Critical appraisal of the health research literature: prevalence or incidence of a health problem

Symptoms of posttraumatic stress, anxiety, depression, levels of resilience and burnout in Spanish Health Personnel during the COVID-19 pandemic

Long-term outcomes of pandemic 2009 influenza A(H1N1)-associated severe ARDS

Increased stressful impact among general population in mainland China amid the COVID-19 pandemic: a nationwide cross-sectional study conducted after Wuhan city's travel ban was lifted

Risk factors for chronic post-traumatic stress disorder (PTSD) in SARS survivors

Prevalence of depression and depressive symptoms among resident physicians a systematic review and meta-analysis

Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Ecological disasters and mental health: causes, consequences, and interventions

Prevalence of depression and posttraumatic stress disorder in adult civilian survivors of war who stay in war-afflicted regions. A systematic review and meta-analysis of epidemiological studies

Post-traumatic stress disorder following disasters: a systematic review

Psychological impact of COVID-19 outbreak on frontline nurses: a cross-sectional survey study

Psychological morbidities and fatigue in patients with confirmed COVID-19 during disease outbreak: prevalence and associated biopsychosocial risk factors

Prevalence of sleep disturbances in Chinese healthcare professionals: a systematic review and meta-analysis

Understanding, compliance and psychological impact of the SARS quarantine experience

Prevalence of post-traumatic symptomatology and anxiety among residential nursing and care home workers following the first COVID-19 outbreak in Northern Italy

Prevalence of post-traumatic stress disorder symptoms in adult critical care survivors: a systematic review and meta-analysis

Psychological impact and associated factors during the initial stage of the coronavirus (COVID-19) pandemic among the general population in Spain

Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic

Mental health outcomes among frontline and second-line health care workers during the coronavirus disease 2019 (COVID-19) pandemic in Italy

COVID-19 pandemic and lockdown measures impact on mental health among the general population in Italy

Tools for assessing quality and susceptibility to bias in observational studies in epidemiology: a systematic review and annotated bibliography

The psychological state and changes in the routine of the patients with rheumatic diseases during the coronavirus disease (COVID-19) outbreak in Turkey: a web-based cross-sectional survey

Mental health outcomes associated with the COVID-19 pandemic: prevalence and risk factors in a southern US state

Psychological impact of COVID-19 on medical care workers in China

Psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease

Psychological impact of the SARS outbreak on a Singaporean rehabilitation department

Mental health status of medical staff in emergency departments during the Coronavirus disease 2019 epidemic in China

Mental health problems faced by healthcare workers due to the COVID-19 pandemic-a review

Drivers of earlier infectious disease outbreak detection: a systematic literature review

Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group

Prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured SARS caring unit during outbreak: a prospective and periodic assessment study in Taiwan

Is returning to work during the COVID-19 pandemic stressful? A study on immediate mental health status and psychoneuroimmunity prevention measures of Chinese workforce

Prevalence and related factors of post-traumatic stress disorder among medical staff members exposed to H7N9 patients

Prevalence and correlates of PTSD and depressive symptoms one month after the outbreak of the COVID-19 epidemic in a sample of home-quarantined Chinese university students

Psychological impact of COVID-19 pandemic in the Philippines

Post-traumatic stress disorder and related factors following the severe acute respiratory syndrome. Chin

Psychological correlates of COVID-19 pandemic in the Austrian population

The forgotten plague: psychiatric manifestations of ebola, zika, and emerging infectious diseases

Initial psychological impact of COVID-19 and its correlates in Indian Community: an online (FEEL-COVID) survey

Psychological impact of deploying in support of the U.S. Response to ebola: a systematic review and meta-analysis of past outbreaks

A longitudinal study on the mental health of general population during the COVID-19 epidemic in China

The prevalence of posttraumatic stress disorder among survivors after a typhoon or hurricane: a systematic review and meta-analysis

Influence of COVID-19 on general stress and posttraumatic stress symptoms among hospitalized high-risk patients

Coronavirus disease (COVID-19) Weekly Epidemiological Update and Weekly Operational Update 2020

A systematic review and meta-regression analysis of aggression during the first episode of psychosis

Posttraumatic stress, anxiety, and depression in survivors of severe acute respiratory syndrome (SARS)

The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk

Survivors of COVID-19 are at high risk of posttraumatic stress disorder

Anxiety state of ordinary residents under novel coronavirus pneumonia epidemic situation and related factors of emergency level

Predictors of symptoms of posttraumatic stress in Chinese university students during the 2009 H1N1 influenza pandemic

Posttraumatic stress symptoms of health care workers during the corona virus disease 2019 (COVID-19)

Difference of posttraumatic stress disorder between severe acute respiratory syndrome patients and the public in epidemic area

Investigation of psychological stress state of during early convalescence of patients with coronavirus disease 2019 and analysis of its influencing factors

The psychological impact of the COVID-19 pandemic on teenagers in China

The correlation between post-traumatic stress disorder and perceived stress in suspected COVID-19 patients quarantined in hospital

Psychological responses and lifestyle changes among pregnant women with respect to the early stages of COVID-19 pandemic

Impact of the COVID-19 pandemic on mental health and quality of life among local residents in Liaoning Province, China: a cross-sectional study

Mental health and its influencing factors among self-isolating ordinary citizens during the beginning epidemic of COVID-19

Investigation on posttraumatic stress reactions in SARS patients

The prevalence of psychiatric symptoms of pregnant and non-pregnant women during the COVID-19 epidemic

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.