The psychological effects of quarantining a cityBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m313 (Published 28 January 2020) Cite this as: BMJ 2020;368:m313
All rapid responses
This is a rapid response article to the January 24th published opinion piece in the British Medical Journal blog, entitled “Coronavirus: The psychological effects of quarantining a city”.
The current outbreak of the novel of coronavirus (COVID-19) in the Hubei provincial capital of Wuhan city has garnered widespread global attention. Wuhan and more than a dozen other cities in the province have been locked down, by travel restrictions into, out of, and within these cities, in an unprecedented quarantine of millions of people, in an effort to control the spread of the virus. Authorities in the world’s most populous country have scrambled to contain the rapid spread of the disease, which has so far spread nationwide in China, and has been reported in neighboring Asian countries and as even far away as in Western and European nations.
A January 24th published opinion piece in the British Medical Journal entitled “Coronavirus: The psychological effects of quarantining a city”, explained that this mass quarantine is likely to have a psychological impact and raise community anxiety in the quarantined populace. This could be seen based on numerous reports in both western media and from personal accounts from residents on Chinese social media. This comes as no surprise, given the memories and similarities of this virus to the SARS (Severe Acute Respiratory Syndrome) pathogen outbreak, which killed hundreds across mainland China and Hong Kong in 2002- 2003, coupled with the regular announcements of an ever increasing infection rate and death toll.
On 27th January 2020, the Chinese National Health Committee released guidelines  for emergency psychological crisis intervention for the coronavirus outbreak, with the objective to “reduce the psychological harm caused by this epidemic and promote social harmony”. This included specific psychological intervention strategies that targeted from hospitalized patients, frontline medical personnel to the general populace.
Although China has many successful experiences in psychological intervention after major catastrophic events, such as the Sichuan Wenchuan and Yushu earthquakes, including the SARS outbreak; for major epidemic diseases, China does not yet have a complete epidemic psychological surveillance system. The psychological intervention during the SARS outbreak lagged behind the peak of the epidemic. As a consequence, the general public was quickly in a state of serious panic. Because infectious disease outbreaks are different from natural disasters, their coverage is wider, the spread is unpredictable, and people's psychological panic is therefore worsened. Due to the ease of becoming excessively panicked from the situation, the related psychological and emotional problems that develop can be more harmful than the virus itself, which was highlighted in the January 24th published opinion article . For example, due to uncontrolled panic brought about by the situation, many people would go to hospitals for medical examinations to seek reassurance. This could result in unnecessary exposure for healthy persons to an already highly infectious environment, thus increasing the chance of cross-infection; and also contribute to a shortage of medical resources for those most in need. At the same time, people's frustration and anxiety over the situation can even easily lead to conflicts between doctors and patients, which can be counterproductive to effective disease treatment, epidemic control, even overall social stability. Therefore, in order to mitigate the psychological impacts of any future epidemics, an independent, province-based psychological early warning system is very important and needed.
China has a vast geographical area and the largest population in the world. Therefore, it is suggested that the Chinese National Health Committee, should consider establishing an independent psychological surveillance system within each province. In the event of any natural disaster or epidemic outbreak, this would facilitate a more rapid response by the mental health services to ease any panic, fear and anxiety within the population; including helping to mitigate the impact of the rumor mill. This is paramount, especially in this time where the internet and social media are common forms of information exchange. This should include psychological monitoring, early warning, information management and psychological prevention and intervention (including intervention hotline). It is the opinion of the authors that the construction of an independent province-based, psychological surveillance system, will help to quickly respond and mitigate the psychological impact caused by natural disasters or epidemics.
Yuping Cao, M.D., Ph.D.
The first author is a Professor of Psychiatry of the Mental Health Institute of the Second Xiangya Hospital, Central South University; and the director of mental rehabilitation in The China National Clinical Research Center on Mental Disorders & National Technology Institute on Mental Disorders, Hunan Mental Health Hospital. She is also vice-chairman of the psycho-counseling and psychotherapy committee of the Chinese Mental Health Association.
Timothy Morgan, M.D.
The second author is a third-Year Psychiatry resident at the Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, China.
1. Rubin G, Wessely S. Coronavirus: the psychological effects of quarantining a city. https://blogs.bmj.com/bmj/2020/01/24/coronavirus-the-psychological-effec... (accessed January 31, 2020).
2. http://www.nhc.gov.cn/xcs/zhengcwj/202001/6adc08b966594253b2b791be5c3b94... (accessed January 31, 2020).
Competing interests: No competing interests
With the rise of the deadly 2019 novel coronavirus (2019-nCoV) originating from Wuhan City in China that is rapidly spreading across Asia, public terror is at its peak. As of 25th of January 2020, the virus has claimed forty-one lives in China, including one of a medical professional. More than 1,370 cases have been confirmed worldwide, with three confirmed cases in Europe.
The Chinese government has since then quarantined 12 cities, impacting on 35 million residents. Thought to be spread via respiratory droplets produced when an infected subject coughs or sneezes, the recommendations for infection control measures by the World Health Organisation include droplet, airborne, contact precautions.
In the midst of the chaos, the price of surgical masks has spiked across Hong Kong, since new cases were confirmed in the Special Administrative Region. As panicked residents flock to local retailers to stock up on surgical masks, some retailers were found to have tripled prices. Normally costing approximately HK$55-60 for a box of 50 masks, some retailers have now increased the price to HK$200 (£20).
Despite claims by retailers that the increase in price is attributed to limited wholesale supply, this unexpected increase in price in a city once plagued by the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak has further fueled public anxiety. To avoid exploitation of consumers and to secure a fair supply to its population, neighbouring region Macau has bulk purchased 20 million surgical masks, with a rationed number available to be purchased by every resident. The Taiwan government has halted its export of surgical masks to ensure adequate supply to its people.
At present there is no strong evidence base to support the regular use of surgical masks in public places to prevent transmission of infectious disease. Previous studies reported reduced transmission rates within close contacts in patients with influenza-like illness, when masks and handwashing were used.[1,2]
However, the Centers for Disease Control and Prevention has recommended the use of surgical masks in patients who are suspected subjects or in those who have had close contact with confirmed cases, to prevent further transmission.
In the midst of an infectious disease outbreak, government action is needed to regulate the prices of protective products such as surgical masks, hand sanitisers, as well as ensuring adequate supply for the population. Public education to impart accurate information regarding preventative measures such as hand hygiene, avoiding close contact with people suffering from acute respiratory infections, avoiding unprotected contact with farm or wild animals is also essential.
1. Cowling B, Chan K, Fang V, et al. Facemasks and hand hygiene to prevent influenza transmission in households: a cluster randomised trial. Ann Intern Med 2009;151:437—46.
2. Simmerman J, Suntarattiwong P, Levy J, et al. Findings from a household randomised controlled trial of hand washing and face masks to reduce influenza transmission in Bangkok, Thailand. Influenza Other Respir Viruses 2011;5:256—67.
Competing interests: No competing interests