PONE-D-20-20196

Investigation of anxiety levels of 1637 healthcare workers during the epidemic of COVID-19

PLOS ONE

Dear Dr. junfen fu,

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PLOS ONE

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[This work was supported by Zhejiang University special research scientific research fund for COVID-19 prevention and control.]

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: No

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is an interesting article exploring anxiety levels and mental health interventions and support for healthcare workers from 5 hospitals in China.

Strengths include: large sample size, random selection of participants

There are several comments that need to be addressed:

-Is there any data on prevalence of depression or acute stress as this impacts anxiety levels.

-Line 74/75: Can the authors explain whether the trained head nurse is a research coordinator or whether he/she has a clinical role? Also can authors provide further details about who checked the questionnaire for validity?

“The researcher explained the purpose and the filling method of the questionnaire to the head nurses. The trained head nurses distributed the electronic questionnaire to the nurses and guided them to fill the questionnaire.”

-Line 87, states: “The total anxiety score of healthcare workers in Zhejiang Province was 30.85 ± 6.89, which was higher than that of Chinese norm 9.78 ± 0.46 [4] 87 (t = 6.273, P < 0.01).”

Methodologically why are the authors comparing prevalence of anxiety of “Chinese norm” from an older reference in the Results section and running any comparison test? I presume it is reference 7 rather than 4 as this is mentioned in the Discussion Line 127/128: “This study showed that the score of anxiety level of healthcare workers in Zhejiang Province was higher than that of Chinese norm [7]”. This reference is discussing anxiety levels during the SARS outbreak in Beijing and uses other measures of psychological distress not assessed in the current study. Further please update the reference in Line 87 as it is incorrect: [4] Lehmann M, Bruenahl CA, Addo MM, Becker S, Schmiedel S, Lohse AW, et al. Acute 179 Ebola virus disease patient treatment and health-related quality of life in health care 180 professionals: A controlled study. J Psychosom Res. 2016; 83:69-74 is a study out of Germany and discusses Ebola so it’s unclear why this is being referenced here at all.

-Line 143/144 “Most nurses were women, facing the physiological period under protective clothing. Their emotions were easy to fluctuate.”

This is a sexist statement and is unacceptable.

-Was an intervention done? The abstract introduction is misleading and if no intervention was done this should be revised

“This study aimed to investigate the anxiety levels of healthcare workers and to provide effective and accurate social and psychological interventions for healthcare workers during the epidemic of COVID-19 in Zhejiang Province, China.”

-The discussion section abruptly ends and needs to be revised for cohesion.

Reviewer #2: I have the following comments for the authors to amend. I will review the reply again.

1) The authors stated "The epidemic of COVID-19 has a huge psychological impact on all social groups." The authors need to be more specific and amend as follows:

The epidemic of COVID-19 has a huge psychological impact on general population (Wang et al 2020), workers (Tan et al 2020), psychiatric patients (Hao et al 2020) and rural population (Tran et al 2020).

References:

Wang C, Pan R, Wan X, et al. (2020) A Longitudinal Study on the Mental Health of General Population during the COVID-19 Epidemic in China [published online ahead of print, 2020 Apr 13]. Brain Behav Immun. 2020; S0889-1591(20)30511-0. doi:10.1016/j.bbi.2020.04.028

Tan W, Hao F, McIntyre RS, et al. Is Returning to Work during the COVID-19 Pandemic Stressful? A Study on Immediate Mental Health Status and Psychoneuroimmunity Prevention Measures of Chinese Workforce [published online ahead of print, 2020 Apr 23]. Brain Behav Immun. 2020;S0889-1591(20)30603-6. doi:10.1016/j.bbi.2020.04.055

Hao F, Tan W, Jiang L, et al. Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A Case-Control Study with Service and Research Implications for Immunopsychiatry [published online ahead of print, 2020 Apr 27]. Brain Behav Immun. 2020;S0889-1591(20)30626-7. doi:10.1016/j.bbi.2020.04.069

Tran BX, Phan HT, Nguyen TPT, et al. Reaching further by Village Health Collaborators: The informal health taskforce of Vietnam for COVID-19 responses. J Glob Health. 2020;10(1):010354. doi:10.7189/jogh.10.010354

2) For the following statement, the authors need to cite references:

Under this background, healthcare workers, especially the first line healthcare workers, are faced with unimaginable challenges.

Reference:

Tan BYQ, Chew NWS, Lee GKH, et al. Psychological Impact of the COVID-19 Pandemic on Health Care Workers in Singapore [published online ahead of print, 2020 Apr 6]. Ann Intern Med. 2020;M20-1083. doi:10.7326/M20-1083

3) Under the discussion, the authors stated "Literature revealed that SARS in

117 2003, Wenchuan earthquake in 2008, Ebola virus in 2014, and MERS, all these emergency

118 events caused different degrees of psychological trauma to the healthcare workers, including

anxiety, insomnia, depression and emotional disorders [2-6]"

Please compare their findings with COVID-19 study instead:

Chew NWS, Lee GKH, Tan BYQ, et al. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak [published online ahead of print, 2020 Apr 21]. Brain Behav Immun. 2020;S0889-1591(20)30523-7. doi:10.1016/j.bbi.2020.04.049

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Reviewer #1: No

Reviewer #2: Yes: Roger Ho

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Submitted filename: Plos One Review 8.2020.docx

Investigation of anxiety levels of 1637 healthcare workers during the epidemic of COVID-19

PONE-D-20-20196R1

Dear Dr. Junfen Fu,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Shawky M. Aboelhadid, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed this reviewer's concerns. I have no further comments/edits/revisions to this manuscript.

Reviewer #2: Thanks you for addressing the comments. I have reviewed the paper and I recommend publication for this paper.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Roger Ho