CHALLENGES FACED BY CORONA WARRIORS DURING COVID-19 PANDEMIC: A REVIEW

Background: The Corona Virus Disease-19 (COVID-19) pandemic is indubitably one of the deadliest events recorded in the 21st century. By the beginning of the year, 2020 the COVID-19 virus has taken the world by surprise and posed a huge challenge to one and all. This pandemic has revealed the existing state of our health care system along with the condition of health care workers (HCWs) with respect to preparedness for such crisis time. During this pandemic, healthcare workers are playing a crucial role in the early detection of cases, contact tracing, and treatment of patients


Introduction
By the beginning of the year, 2020 the COVID-19 virus has taken the world by surprise and posed a huge challenge for health care workers and institutions. The COVID-19 is known to be highly contagious as its transmission occurs by contact with an infected person, droplets, fomites etc. The patients who comes positive shows early symptoms of respiratory distress, cough with or without fever, diarrhea, weakness. 1,2 The World health organization on 11 th January 2020 announced that a novel corona virus was the root cause for a respiratory illness in a cluster of people in Wuhan city, China, and declared COVID-19 a pandemic on 11th March 2020. A student who returned from Wuhan was believed to be the first case of COVID-19 virus in India on 30 th January 2020 in Thrissur, Kerala. 3

Impact of COVID-19 pandemic on the global health care system
Over 200 countries worldwide are affected by the novel corona virus and their healthcare systems are crumbling to deploy the maximum possible resources to mitigate the spread of COVID-19 infection and reduce morbidity and mortality. We are witnessing a century's crisis where the whole world is under threat of rapidly spreading new COVID -19 infections having the most devastating effect globally. 1 With more than 3 million innocent lives lost and the counts on the surge, the pandemic has strained and tested not only the health care system, our knowledge of determinants of this disease causation and containment but also realms outside healthcare like the economy, the political system of any country. 4 , 5 The overall global impact of this new pandemic is yet uncertain.
More than 30 million reported cases of COVID-19 infection and more than 4lakhsdeathsIndia reported highest number of confirmed cases of COVID-19 in Asia and ranking the second-highest number of confirmed cases in the world after the United States. The per-day cases peaked mid-September 2020 in India with over 90,000 cases reported per day and since have come down to below 40,000 in December 2020. 3,6 The present article is focusing challenges faced by health care workers and institutions during COVID-19 pandemic and reiterate the lessons learned from this pandemic and, challenges that will work as template for preparedness for future pandemics.

Method and Material
This article discusses the on challenges and coping strategies during the current situation affecting health care workers who are fighting and responding to the war against the COVID-19 pandemic. An open-access literature search was conducted from June 2020 to January 2021, using multiple databases/search engine including Medline, Pub Med, and Google Scholar. The following keywords-Pandemic, Health care worker, COVID-19, challenges, psychological health, stress, fear were searched. The first search section involves difficulty to health care workers including common stressors like the uncertainty of ultimate magnitude, duration, and the effects of the crisis during a pandemic, psychological impact of COVID-19 on HCWs, working environment, regular supply of personal protective gears (PPE). The second search type involves coping strategies, mentorship, and facilities for health care workers, incidences of violence against health care workers. Additionally, a gray literature search was also conducted to find epidemiological and COVID-19 management-related evidence.

Inclusion criteria:
• Research studies exploring challenges faced by health care workers during the COVID-19 pandemic.
• Studies published in the English language • Primary research studies, review articles, letter to editors focusing on health care workers, COVID patients 'difficulties in the COVID-19 era.

Exclusion criteria:
• Studies that do not mention data collection and analysis or source of data • Non-peer-reviewed journal articles, letters • Research studies with no direct view, opinion, or quotes from Health care workers

Ethical Consideration:
The review has included sources references and their information's. As intervention objective is not included in this paper, no permission was sought from Ethical committee for the review.

Results
The details on the literature search and processes of screening are illustrated in Fig number 1  In the pandemic crisis, when the world is facing a shortage of trained health care workers and the current health care system is already under pressure, the death of the HCWs is further reducing our struggling capability against COVID-19.

Challenges beyond the Risk of Infection
Infectious diseases have a great risk of psychological responses, but not everyone has gone through the same experience and a similar degree of emotional impact. The highly contagious behavior of the COVID-19 virus is tending health care workers to go through a variety of emotional and psychological problems. [10][11] The Center for Disease Control and Prevention, China reported over three thousand HCWs got infected with the COVID -19 virus. Several studies across the world are being conducted to safeguard health care workers and to curb the further risk of spreading the virus. This is crucial to inquire more information about risk to healthcare workers from the COVID-19 pandemic and the coping strategies being used by them. [11][12] A study was carried out in China at their Tongji Hospital to identify a high rate of severe COVID-19 infection among their medical staff wherein 54 team members were found to be infected by the virus. The majority of health care professionals were from the emergency area of that hospital. Out of 54 COVID-19 positive health care team members, 11 were found to have common grade infection, the other 40 were severe grade, and three were having critical grade infection. The study also suggests advanced induction training for all hospital staff to minimize the risk of infection and raise the need to educate the departments that are not having a direct flow of COVID-19 infected patients in their area. 13

Previous Pandemic Experiences
The COVID-19 pandemic is not the first pandemic that has tested the structure, strength, and resilience of our health care system. The past century has witnessed major pandemics viz Spanish flu in 1918 caused by influenza A (H1N1) killed around 20-50 million people, others in 1957 and 1968 relatively milder but still killed nearly one million. 14 During the Middle East Respiratory Syndrome (MERS) outbreak in the year 2015 in Korea, health-related worries and safety concerns of the health care workers were one of the most primary stressors among those who were assigned to performMERS-related patient care. These health care workers showed higher rates of stress, avoidance, and sleep disturbance problems. 15 Another cross-sectional study conducted at hospitals of the Ministry of National Guard during the MERS outbreak in Saudi Arabia depicted that out of 1031 study participants, about two-third of study participants showed the risk of MERS CoV infection, perceived insecurity, and stress during providing patient care. 16 Ebola outbreak episode during 2014-2015 was considered one of the deadliest, resulting in over 10 thousand deaths. A study from China during the Ebola outbreak to assess the prevalence of psychological symptoms and impact of the Ebola epidemic among Ebola survivors and healthcare workers reported a higher rate of depression, anxiety, and stress in health care workers. The study also suggested developing an emergency response plan for health care institutions. 15 Maunder RG et al study findings are significant with the SARS outbreak study where health care worker reported much higher levels of panic and perceived risk of getting self and family members infected, moral disturbance, and stigmatization. 17 Finding reported by Dr. Mian-Yoon Chong's study on the SARS outbreak in Taiwan depicted two-thirds of health care workers experienced psychiatric morbidity due to fear and anxiety of disease. 18 Learning from the experiences of the COVID-19 pandemic as well as from previous pandemics, impetus is there to develop or improve the existingpreparedness and response plan in a manner that enables the organizations to continue providing routine healthcare services along with managing the pandemics.

The Psychological Impact of COVID-19 on HCWs
Fear of pandemics is the breeding ground for anxiety with limited shreds of evidence of specific medical treatment support in absence of vaccine availability. The visible and hidden impact of working in the COVID-19 area is reported in multiple studies as an immediate threat to self-safety and family health concerns, anxiety and fear, sleep disturbances, intrusive thoughts, and depression. 19 Studies reported how the COVID-19 pandemic was emotionally distressing to health care workers as they were more worried about getting infected and then transferring the same to their families. It raised concern for their safety. 20 Health care workers who are posted in the direct care of COVID-19 infected patients are also facing stigma in society and sometimes even in their own families. The troublesome characteristics of COVID-19 is high infectivity rate, no specific treatment in a strain of virus initiate fear and behavior of avoidance within healthcare worker. 21 The COVID-19vaccination drive has started with intention to give priority to health care and frontline COVID warriors.
Many millionpeople have received COVID Vaccine and the government is putting all efforts in COVID vaccination program that may break the chain of infection. 22 Several incidences were reported soon after the pandemic spread,whereinlandlords forced their tenants to vacate or shift their accommodation as they were health care workers proving care to suffering patients. The role of rumors and misinformation cannot be denied behind such behavior. Although many countries have strict laws and legislations for violence against health care workers still the same are being reported and published as heading in newspaper. 22 Health care workers have and are providing round the clock services (in shifts duties) to ensure continuity of treatment in hospitals with the cost of the high risk of infection. Risk factors affecting mental health include the stressful, high demanding working environment, availability of ample PPE and risk of the family getting infected. 24 Sudden changes in working conditions, staying far from family during the quarantine period, and the extension of working shifts resulting in serious mental and physical stress. 24

Violence against Healthcare Workers
World Health Organization (WHO) defined workplace violence as Incidents where the staff is abused, threatened, or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being, or health. Another observation found during the COVID-19 pandemic that the incidence of violence against health care workers was believed to be at four times higher risk than other professionals worldwide. [25][26] Violence against health professionals is an age-old problem.However, during the COVID pandemic, on one handthe world is clapping for health care workers as savior and warriors, but on the other, increasing incidence of assault and violence are narrating a different story. 27

Personal Protective Eqipment availability
Shortage of PPE was reported worldwide due to a rise in demand, panic-buying, and irrational use. 13 In the initial phase of the pandemic, there was a scarcity of proper PPE kits due to which the HCWs had no choice but to treat the patients with whatever PPE was available, and while treating like this they even had direct contact with the patients. This contributed to an increase in fear and risk to HCWs, as they were expected to work in the environment where aerosolgenerating procedures were carried out and also unknowingly direct contact with a patient lead to exposures. 7 During the initial COVID-19 pandemic, one of the worst affected region in the world, northern Italy experience indicated more than 25000 COVID-19 warriors have been infected with this infection and the death of over one hundred fifty physicians. 28 A study conducted in China showed frontline HCWs working in COVID-19 affected areas faced a shortage of personal protective equipment, fear of transferring the infection to their home and family members. About one-third of study participants (34.0%) had experienced sleep disturbance, fear, and 44.6% reported anxiety whereas half of the participants (50.4%) had a risk of depression where 71.5% participants reported stress. 29 Provision of vaccination and diagnostic kit, and the announcement of best possible compensation.The uninterrupted supply of adequate safety measures is important to ensure the safety of human resources. 30

Misinformation about pandemic
COVID-19 is also being called the first truly modern pandemic in the present century on social media and there is quite a free flow of unconfirmed information and misinformation about the Pandemic. The uncontrolled flow of information on social media and news media is creating the pandemic into an infodemic.
Unconfirmed information about any disease can result in difficult consequences and confusion about the mode of spread and the incubation period of the disease. Constantly receiving misleading information on infection extends rumors of mass mortality can create a worrying environment.

31, 32
The trusted and coordinated information can help to stop furtherspread of disease,whereas false information can further add to the next wave of the pandemic and may cause great loss of life.

Coping Strategies to Combat the Challenges
COVID-19 pandemic has dangerously exposed health workers and their families to extraordinary levels of infection risk, add insult to their psychological health and fear fighting spirit. 21,22 The world health organization (WHO) is taking many initiatives for keeping health care workers safe.It's the responsibility of health organizations also to keep their employees healthy and fit. Institutions are required to form an Infection Prevention and Control committee to identify health care workers' needs.

Mentorship and support
• Expressing feelings and emotions rather than bottling them up cankeep healthcare workers feel light-hearted. In this context,friends and family are a strong source of psychological support with whom HCWs can share feelings and emotions openly.
• Discussion with colleagues who are going through similar experiences can give more insight into their coping mechanism.
• Being positive is sometimes the only choice. This COVID pandemic battle is going to be long and it may take time to control the impact of the pandemic, but it is expected that its effect will decrease and then it can be treated as any other endemic disease.

Physical health care
• Physical activities are essential to keep a person well, active and helps to maintain immunity, sound sleep, and hunger regulation.
• Promote physical activities like regular exercise, yoga, meditation, and indoor sports (if possible).
• Recreational activities like listening to music, painting, and reading book etc. can be motivated. Excessive use of coffee, smoking, or alcoholic drinks is to be avoided andmaintenance of hydration may mitigate stress.

Tele-health initiative
COVID-19 pandemic has suddenly raised the need for contactless real-time experience for patients to care, training, and mass communication as isolation and social distancing is requirement of this new disease.
• Tele conferencing minimizes the risk of personal contact and risk of exposure. It facilitates in providing virtual training of health care workers thereby preventing potential transmission of COVID -19 viruses to others. 33 • As the COVID-19 pandemic scales exponentially across the world, it calls for the expanded use of telehealth as innovative solutions, clearly highlightunmet needs in the global healthcare system.

Rotational duty hours of COVID posting
• A systematic rotation plan ofduty of staff minimizes repetition and can provide maximum rest in between two shifts. Many studies reported the benefits of a short night shift or nap in between for better work output and alertness, that can result in increased performance and improvement in physiologic alertness as compared to the no nap or rest condition. 34

Other Important factors to preserve motivation level of HCWs
• Ensure uninterrupted supplies of PPEs, hand sanitizers, and other consumables. Provision of antiviral medications, vaccines etc. • Development of standard guidelines regarding the handling of suspected and confirmed COVID patients, transferring of patients to another specialty area, doffing& donning of protective gears.
• Screening for all staff during and after COVID-19 posting including routine health assessment and policy for timely treatment, reimbursement/compensation if any for staff who develops COVID-19 infection.

Conclusion
Health care workers are the most important resource for any nation and to safeguard them with sufficient provision of protective equipment and support is a priority. COVID-19 pandemic may also be considered as opportunity to improve health care access, quality, and safety of health care and promotion of healthy lifestyles in days to come.