It hurts your heart: frontline healthcare worker experiences of moral injury during the COVID-19 pandemic

BackgroundMoral injury is defined as the strong emotional and cognitive reactions following events which clash with someones moral code, values or expectations. During the COVID-19 pandemic, increased exposure to potentially morally injurious events (PMIEs) has placed healthcare workers (HCWs) at risk of moral injury. Yet little is known about the lived experience of cumulative PMIE exposure and how NHS staff respond to this. ObjectiveWe sought to rectify this knowledge gap by qualitatively exploring the lived experiences and perspectives of clinical frontline NHS staff who responded to COVID-19. MethodsWe recruited a diverse sample of 30 clinical frontline HCWs from the NHS CHECK study cohort, for single time point qualitative interviews. All participants endorsed at least one item on the 9-item Moral Injury Events Scale (MIES) (Nash et al., 2013) at six month follow up. Interviews followed a semi-structured guide and were analysed using reflexive thematic analysis. ResultsHCWs described being routinely exposed to ethical conflicts, created by exacerbations of pre-existing systemic issues including inadequate staffing and resourcing. We found that HCWs experienced a range of mental health symptoms primarily related to perceptions of institutional betrayal as well as feeling unable to fulfil their duty of care towards patients. ConclusionThese results suggest that a multi-facetted organisational strategy is warranted to prepare for PMIE exposure, promote opportunities for resolution of symptoms associated with moral injury and prevent organisational disengagement. HighlightsO_LIClinical frontline healthcare workers (HCWs) have been exposed to an accumulation of potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic, including feeling betrayed by both government and NHS leaders as well as feeling unable to provide duty of care to patients C_LIO_LIHCWs described the significant adverse impact of this exposure on their mental health, including increased anxiety and depression symptoms and sleep disturbance C_LIO_LIMost HCWs interviewed believed that organisational change within the NHS was necessary to prevent excess PMIE exposure and promote resolution of moral distress C_LI

Unexplained longitudinal variability in COVID-19 antibody status by Lateral Flow Immuno-Antibody testing

BackgroundCOVID-19 antibody testing allows population studies to classify participants by previous SARS-CoV-2 infection status. Home lateral flow immune-antibody testing devices offer a very convenient way of doing this, but relatively little is known about how measurement and antibody variability will affect consistency in results over time. We examined consistency by looking at the outcome of two tests three months apart while COVID-19 infection rates were low (summer 2020 in the UK). MethodsThe KCL-Coronavirus Health and Experiences in Colleagues at Kings is an occupational cohort of staff and postgraduate research students. Lateral flow immune-antibody testing kits were sent to participants homes in late June 2020 and late September 2020. Participants also completed regular surveys that included asking about COVID-19 symptoms and whether they thought they had been infected. ResultsWe studied 1489 participants returned valid results in both June and September (59% of those sent kits). Lateral flow immune-antibody test was positive for 7.2% in June and 5.9% in September, with 3.9% positive in both. Being more symptomatic or suspecting infection increased the probability of ever being positive. Of those positive in June, 46% (49/107) were negative in September (seroreversion), and this was similar regardless of symptom characteristics, suspicion, and timing of possible infection. A possible outlier was those aged over 55 years, where only 3 of 13 (23%) had seroreversion. DiscussionThese results do not follow the pattern reported from studies specifically designed to monitor seropositivity, which have found greater consistency over time and the influence of presence, timing and severity of symptoms on seroreversion. We suggest several factors that may have contributed to this difference: our low bar in defining initial seropositivity (single test); a non-quantitative test known to have relatively low sensitivity; participants carrying out testing. We would encourage other studies to use these real-world performance characteristics alongside those from laboratory studies to plan and analyse any antibody testing.

NHS CHECK: protocol for a cohort study investigating the psychosocial impact of the COVID-19 pandemic on healthcare workers

IntroductionThe COVID-19 pandemic has had profound effects on the working lives of healthcare workers (HCWs), but the extent to which their well-being and mental health have been affected remains unclear. This longitudinal cohort study aims to recruit a cohort of NHS healthcare workers, conducting surveys at regular intervals to provide evidence about the prevalence of symptoms of mental disorders, investigate associated factors such as occupational contexts and support interventions available. Methods and AnalysisAll staff, students, and volunteers working in each of the 18 participating NHS Trusts in England will be sent emails inviting them to complete a survey at baseline, with email invitations for the follow up surveys being sent 6 and 12 months later. Opening in late April 2020, the baseline survey collects data on demographics, occupational and organisational factors, experiences of COVID-19, a number of validated measures of symptoms of poor mental health (e.g. depression, anxiety, post-traumatic stress disorder; PTSD), and measures of constructs such as resilience and moral injury. These regular surveys will be complemented by in-depth psychiatric interviews with a select sample of healthcare workers. Qualitative interviews will also be conducted, to gain deeper understanding of the support programmes used or desired by staff, and facilitators and barriers to accessing such programmes. Ethics and DisseminationEthical approval for the study was granted by the Health Research Authority (reference: 20/HRA/210, IRAS: 282686) and local Trust Research and Development approval. Cohort data are being collected via Qualtrics online survey software, are pseudonymised and held on secure University servers. Participants are aware that they can withdraw from the study at any time, and there is signposting to support services for any participant who feels they need it. Only those consenting to be contacted about further research will be invited to participate in the psychiatric and qualitative interview components of the study. Findings will be rapidly shared with NHS Trusts to enable better support of staff during the pandemic, and via academic publications in due course. Strengths and limitations of this studyO_LIThe longitudinal cohort design addresses the lack of long-term data on this population, and the current predominance of cross-sectional evidence available. C_LIO_LIThe availability of Trust HR data means we will be able to calculate response rates, and weight the data appropriately. C_LIO_LIThe diagnostic interview component of the study will allow us to establish the true prevalence of mental disorders, which can be inflated by the measures used in most mental health and wellbeing cohort studies. C_LIO_LIThe qualitative interviews will give deeper insight into the support programmes that HCWs find most helpful, and provide ideas for Trusts to improve their offer to staff. C_LIO_LIThe three components of the study give breadth and depth lacking in much of the mental health and wellbeing research currently available, but there is a risk of over-burdening already stretched HCWs. C_LI

The King's College London Coronavirus Health and Experiences of Colleagues at King's Study: SARS-CoV-2 antibody response in a higher education sample

ObjectiveTo assess the feasibility of home antibody testing as part of large-scale study, the Kings College London Coronavirus Health and Experiences of Colleagues at Kings (KCL CHECK). MethodsParticipants of the KCL CHECK study were sent a SureScreen Diagnostics COVID-19 IgG/IgM Rapid Test Cassette to complete at home in June 2020 (phase 1) and September 2020 (phase 2). Participants were asked to upload a test result image to a study website. Test result images and sociodemographic information were analysed by the research team. ResultsA total of n=2716 participants enrolled in the KCL CHECK study, with n=2003 (73.7%) and n=1825 (69.3%) consenting and responding to phase 1 and 2. Of these, n=1882 (93.9%; phase 1) and n=1675 (91.8%; phase 2) returned a valid result. n=123 (6.5%; phase 1) and n=91 (5.4%; phase 2) tested positive for SARS-CoV-2 antibodies. A total of n=1488 participants provided a result in both phases, with n=57 (3.8%) testing positive for SARS- CoV-2 antibodies across both phases, suggesting a reduction in the number of positive antibody results over time. Initial comparisons showed variation by age group, gender and clinical role. ConclusionsOur study highlights the feasibility of rapid, repeated and low-cost SARS-CoV-2 serological testing without the need for face-to-face contact. What is already known about this subject?Higher education institutions have a duty of care to minimise the spread and transmission of COVID-19 in its campuses, and among staff and students. The reopening of higher education buildings and campuses has brought about a mass movement of students, academics and support staff from across the UK. Serological antibody studies can assist by highlighting groups of people and behaviours associated with high risk of COVID-19. What are the new findings?We report a framework for SARS-CoV-2 serological antibody testing in an occupational group of postgraduate research students and current members of staff at Kings College London. Over two phases of data collection, 6.5% (phase 1) and 5.4% (phase 2) tested positive for SARS-CoV-2 antibodies, with only 3.8% testing positive for antibodies in both phases, suggesting a reduction in positive antibody results over time. How might this impact on policy or clinical practice in the foreseeable future?Our study highlights the feasibility of rapidly deploying low-cost and repeatable SARS-CoV-2 serological testing, without the need for face-to-face contact, to support the higher education system of the UK.

The psychosocial impact of the COVID-19 pandemic on 4,378 UK healthcare workers and ancillary staff: initial baseline data from a cohort study collected during the first wave of the pandemic.

ObjectivesThis study reports preliminary findings on the prevalence of, and factors associated with, mental health and wellbeing outcomes of healthcare workers during the early months (April-June) of the COVID-19 pandemic in the UK. MethodsPreliminary cross-sectional data were analysed from a cohort study (n=4,378). Clinical and non-clinical staff of three London-based NHS Trusts (UK), including acute and mental health Trusts, took part in an online baseline survey. The primary outcome measure used is the presence of probable common mental disorders (CMDs), measured by the General Health Questionnaire (GHQ-12). Secondary outcomes are probable anxiety (GAD-7), depression (PHQ-9), Post-Traumatic Stress Disorder (PTSD) (PCL-6), suicidal ideation (CIS-R), and alcohol use (AUDIT). Moral injury is measured using the Moray Injury Event Scale (MIES). ResultsAnalyses showed substantial levels of CMDs (58.9%, 95%CI 58.1 to 60.8), and of PTSD (30.2%, 95%CI 28.1 to 32.5) with lower levels of depression (27.3%, 95%CI 25.3 to 29.4), anxiety (23.2%, 95%CI 21.3 to 25.3), and alcohol misuse (10.5%, 95%CI, 9.2 to 11.9). Women, younger staff, and nurses tended to have poorer outcomes than other staff, except for alcohol misuse. Higher reported exposure to moral injury (distress resulting from violation of ones moral code) was strongly associated with increased levels of CMDs, anxiety, depression, PTSD symptoms, and alcohol misuse. ConclusionsOur findings suggest that mental health support for healthcare workers should consider those demographics and occupations at highest risk. Rigorous longitudinal data are needed in order to respond to the potential long-term mental health impacts of the pandemic. HighlightsO_ST_ABSWhat is already known about this subject?C_ST_ABSO_LILarge-scale population studies report increased prevalence of depression, anxiety, and psychological distress during the COVID-19 pandemic. C_LIO_LIEvidence from previous epidemics indicates a high and persistent burden of adverse mental health outcomes among healthcare workers. C_LI What are the new findings?O_LISubstantial levels of probable common mental disorders and post-traumatic stress disorder were found among healthcare workers. C_LIO_LIGroups at increased risk of adverse mental health outcomes included women, nurses, and younger staff, as well as those who reported higher levels of moral injury. C_LI How might this impact on policy or clinical practice in the foreseeable future?O_LIThe mental health offering to healthcare workers must consider the interplay of demographic, social, and occupational factors. C_LIO_LIAdditional longitudinal research that emphasises methodological rigor, namely with use of standardised diagnostic interviews to establish mental health diagnoses, is necessary to better understand the mental health burden, identify those most at risk, and provide appropriate support without pathologizing ordinary distress responses. C_LI

Indicators of COVID-19 status in a cohort study of university staff and post-graduate research students, including results from home antibody testing

Background Definitive diagnosis of COVID-19 requires resources frequently restricted to the severely ill. Cohort studies must rely on surrogate indicators to define cases of COVID-19 in the community. We describe the prevalence and overlap of potential indicators including self-reported symptoms, suspicion, and routine test results, plus home antibody testing. Methods An occupational cohort of 2807 staff and postgraduate students at a large London university. Repeated surveys covering March to June 2020. Antibody test results from 'lateral flow' IgG/IgM cassettes in June 2020. Results 1882 participants had valid antibody test results, and 124 (7%) were positive. Core symptoms of COVID-19 were common (770 participants positive, 41%), although fewer met criteria on a symptom algorithm (n=297, 16%). Suspicion of COVID-19 (n=509, 27%) was much higher than positive external tests (n=39, 2%). Positive antibody tests were rare in people who had no suspicion (n=4, 1%) or no core symptoms (n=10, 2%). In those who reported external antibody tests, 15% were positive on the study antibody test, compared with 24% on earlier external antibody tests. Discussion Our results demonstrate the agreement between different COVID indicators. Antibody testing using lateral flow devices at home can detect asymptomatic cases and provide greater certainty to self-report; but due to weak and waning antibody responses to mild infection, may under-ascertain. Multiple indicators used in combination can provide a more complete story than one used alone. Cohort studies need to consider how they deal with different, sometimes conflicting, indicators of COVID-19 illness to understand its long-term outcomes.

The King's College London Coronavirus Health and Experiences of Colleagues at King's Study: SARS-CoV-2 antibody response in an occupational sample

We report test results for SARS-CoV-2 antibodies in an occupational group of postgraduate research students and current members of staff at Kings College London. Between June and July 2020, antibody testing kits were sent to n=2296 participants; n=2004 (86.3%) responded, of whom n=1882 (93.9%) returned valid test results. Of those that returned valid results, n=124 (6.6%) tested positive for SARS-CoV-2 antibodies, with initial comparisons showing variation by age group and clinical exposure.

Molecular Variation and Distribution of Anopheles fluviatilis (Diptera: Culicidae) Complex in Iran

Anopheles fluviatilis James (Diptera: Culicidae) is one of the known malaria vectors in south and southeastern Iran. Earlier ITS2 sequences analysis of specimens from Iran demonstrated only a single genotype that was identical to species Y in India, which is also the same as species T. We identified 2 haplotypes in the An. fluviatilis populations of Iran based on differences in nucleotide sequences of D3 domain of the 28S locus of ribosomal DNA (rDNA). Comparison of sequence data from 44 Iranian specimens with those publicly available in the Genbank database showed that all of the 28S-D3 sequences from Kazeroun and Khesht regions in Fars Province were identical to the database entry representing species U in India. In other regions, all the individuals showed heterozygosity at the single nucleotide position, which identifies species U and T. It is argued that the 2 species may co-occur in some regions and hybridize; however, the heterozygosity in the 28S-D3 locus was not reflected in ITS2 sequences and this locus for all individuals was identical to species T. This study shows that in a newly diverged species, like members of An. fluviatilis complex, a single molecular marker may not be sufficiently discriminatory to identify all the taxa over a vast geographical area. In addition, other molecular markers may provide more reliable information for species discrimination.

Isolation and initial characterization of the tellurite reducing moderately halophilic bacterium, Salinicoccus sp. strain QW6.

Among the 49 strains of moderately halophilic bacteria isolated from the salty environments of Iran, a Gram-positive coccus designated as strain QW6 showed high capacity in the removal of toxic oxyanions of tellurium in a wide range of culture medium factors including pH (5.5-10.5), temperature (25-45 degrees C), various salts including NaCl, KCl, and Na(2)SO(4) (0.5-4 M), selenooxyanions (2-10 mM), and at different concentrations of potassium tellurite (0.5-1 mM) under aerobic condition. Phenotypic characterization and phylogenetic analyses based on 16S rDNA sequence comparisons indicated that this strain was a member of the genus Salinicoccus. The maximum tellurite removal was exhibited in 1.5M NaCl at 35 degrees C, while the activity reduced by 53% and 47% at 25 and 45 degrees C, respectively. The optimum pH for removal activity was shown to be 7.5, with 90% and 83% reduced removal capacities at the two extreme values of 5.5 and 10, respectively. The impact of different concentrations of selenooxyanions (2-10 mM) on tellurite removal by strain QW6 was evaluated. The ability of strain QW6 in the removal of tellurite in the presence of 6mM selenite increased by 25%. The concentration of toxic potassium tellurite in the supernatant of the bacterial culture medium decreased by 99% (from 0.5 to 0.005 mM) after 6 days and the color of the medium changed to black due to the formation of less toxic elemental tellurium.

Production of an extracellular alkaline metalloprotease from a newly isolated, moderately halophile, Salinivibrio sp. strain AF-2004.

An extracellular protease was produced under stress conditions of high temperature and high salinity by a newly isolated moderate halophile, Salinivibrio sp. strain AF-2004 in a basal medium containing peptone, beef extract, glucose and NaCl. A modification of Kunitz method was used for protease assay. The isolate was capable of producing protease in the presence of sodium chloride, sodium sulfate, sodium nitrate, sodium nitrite, potassium chloride, sodium acetate and sodium citrate. The maximum protease was secreted in the presence of 7.5 to 10% (w/v) sodium sulfate or 3% (w/v) sodium acetate (4.6 U ml(-1)). Various carbon sources including glucose, lactose, casein and peptone were capable of inducing enzyme production. The optimum pH, temperature and aeration for enzyme production were 9.0, 32 degrees C and 220 rpm, respectively. The enzyme production corresponded with growth and reached a maximum level during the mid-stationary phase. Maximum protease activity was exhibited in the medium containing 1% (w/v) NaCl at 60 degrees C, with 18% and 41% activity reductions at temperature 50 and 70 degrees C, respectively. The optimum pH for enzyme activity was 8.5, with 86% and 75% residual activities at pH 10 and 6, respectively. The activity of enzyme was inhibited by EDTA. These results suggest that the protease secreted by Salinivibrio sp. strain AF-2004 is industrially important from the perspectives of its activity at a broad pH ranges (5.0-10.0), its moderate thermoactivity in addition to its high tolerance to a wide range of salt concentration (0-10% NaCl).

A preliminary study of genetic diversity of MSP-1 types in Plasmodium falciparum in southern province of Sistan Baluchistan of Iran.

Plasmodiumfalciparum merozoite surface protein-1 (MSP-1) shows extensive antigenic diversity. This is due to the presence of seven variable blocks, five semi-conserved and also five conserved blocks. The variable blocks in the MSP-1 gene are principally dimorphic, displaying either K1 or MAD20 type; except for the block 2 region which is represented by three alleles, an RO33 type in addition to the other two. Allelic diversity is reported to be generated by intra-genic recombination between the variable blocks. A study of allelic variation of MSP-1 gene in Plasmodium falciparum was carried out in the southern province of Sistan Baluchistan in Iran in 2001-2003. Samples were obtained from 30 febrile patients and DNA was extracted and association types between blocks 2 and 6 was identified on each block using specific primers and compared with those from Vietnam, Brazil and Africa. The association types obtained, were similar though less in number than the ones from Vietnam, but more than those from Africa and Brazil.