Stress resilience during the coronavirus pandemic

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www.elsevier.com/locate/euroneuro

CONSENSUS

STATEMENT

Stress

resilience

during

the

coronavirus

pandemic

Christiaan

H. Vinkers

a,b,∗

,

Therese

van

Amelsvoort

c

,

Jonathan

I. Bisson

d

,

Igor

Branchi

e

,

John

F. Cryan

f

,

Katharina

Domschke

g,h

,

Oliver

D. Howes

i

,

Mirko

Manchia

j,k,l

,

Luisa

Pinto

m,n

,

Dominique

de

Quervain

o

,

Mathias

V. Schmidt

p

,

Nic

J.A.

van

der

Wee

q

a_Department_of_Psychiatry_(GGZ_inGeest),_Amsterdam_UMC_(location_VUmc),_Vrije_University,

AmsterdamPublicHealthandAmsterdamNeuroscienceresearchinstitutes,Amsterdam,The Netherlands

b_Department_of_Anatomy_and_{Neurosciences,}_Amsterdam_UMC_(location_VUmc),_Vrije_University,

Amsterdam,TheNetherlands

c_Department_of_Psychiatry_and_{Neuropsychology,}_Maastricht_University,_Maastricht,_The_Netherlands d_Division_of_{Psychological}_Medicine_and_Clinical_{Neurosciences,}_{Cardiff University}_School_of_Medicine,

Cardiff,UK

e_Center_for_Behavioral_Sciences_and_Mental_Health,_Istituto_Superiore_di_Sanità,_Rome,_Italy f_Dept_Anatomy_&_{Neuroscience,}_University_College_Cork,_Cork,_Ireland_&_APC_Microbiome_Ireland,

UniversityCollegeCork,Cork,Ireland

g_Dept._of_Psychiatry_and_{Psychotherapy,}_Medical_Center_{– University}_of_Freiburg,_Faculty_of_Medicine,

UniversityofFreiburg,Freiburg,Germany

h_Center_for_Basics_in_{NeuroModulation,}_Faculty_of_Medicine,_University_of_Freiburg,_Freiburg,_Germany i_Institute_of_Psychiatry,_Psychology_and_{Neurosciences,}_King’s_College_London,_London,_UKMRC_London

InstituteofMedicalSciences,ImperialCollegeLondon,London,UK

j_Section_of_Psychiatry,_Department_of_Medical_Sciences_and_Public_Health,_University_of_Cagliari,

Cagliari,Italy

k_Unit_of_Clinical_Psychiatry,_University_Hospital_Agency_of_Cagliari,_Cagliari,_Italy l_Department_of_{Pharmacology,}_Dalhousie_University,_Halifax,_Nova_Scotia,_Canada

m_Life_and_Health_Sciences_Research_Institute_(ICVS),_School_of_Health_Sciences,_University_of_Minho,

Braga,Portugal

n_ICVS/3B’s_-_PT_Government_Associate_Laboratory,_{Braga/Guimarães,}_Portugal

o_Division_of_Cognitive_{Neuroscience,}_Department_of_Psychology,_Department_of_Medicine,_University_of

Basel,Switzerland

p_Research_Group_Neurobiology_of_Stress_Resilience,_Max_Planck_Institute_of_Psychiatry,_Munich,_Germany

∗_{Corresponding}_author.

E-mailaddress:c.vinkers@amsterdamumc.nl(C.H.Vinkers). https://doi.org/10.1016/j.euroneuro.2020.05.003

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q_Department_of_Pschiatry,_Leiden_University_Medical_Center,_Leiden,_the_Netherlands,_Leiden_Institute

forBrainandCognition,Leiden,TheNetherlands

Received 3April2020;receivedinrevisedform17April2020;accepted1May2020

KEYWORDS COVID-19; Corona; Coronavirus; Pandemic; SARS-CoV-2; Stressvulnerability; Mentalhealth; Psychiatricdisorders; Resilience; Interventionstrategies Abstract

Theepidemicofthe2019novelcoronavirusSARS-CoV-2,causingthecoronavirusdisease2019 (COVID-19) isaglobal publichealth emergency with multifaceted severe consequences for people’slivesandtheirmentalhealth.Inthisarticle,asmembersoftheEuropeanCollegeof Neuropsychopharmacology(ECNP)Resilience,wewilldiscuss theurgentneedfor afocuson resilienceduringthecurrentcoronaviruspandemic.Resilienceispivotaltocopewithstress andvitaltostayinbalance.Wewilldiscusstheimportanceofresilienceattheindividualand societallevel,butalsotheimplicationforpatientswithapsychiatricconditionandhealthcare workers.Wenotonlyadvocateforanincreasedfocusonmentalhealthduringthecoronavirus pandemicbut also highlightthe urgent needofaugmenting our focusonresilience andon strategiestoenhanceit.

Theepidemicofthe2019novelcoronavirusSARS-CoV-2, causing thecoronavirus disease 2019(COVID-19), ﬁrst ex-pandedwithintheWuhanregioninChinaandquicklyspread toEuropeandtotherestoftheworld(Zhouetal.,2020). The outbreakof COVID-19is a global public health emer-gencywithmultifacetedsevere consequencesforpeople’s livesandtheirmentalhealth.Inthisarticle,asmembersof theEuropeanCollegeofNeuropsychopharmacology(ECNP) Resilience,wewilldiscusstheurgentneedforafocuson re-silienceduringthecurrentcoronaviruspandemic.Resilience is pivotal tocopewithstress andvitaltostayin balance. Wewilldiscusstheimportanceofresilienceatthe individ-ualandsocietallevel,butalsotheimplicationforpatients withapsychiatricconditionandhealthcareworkers.

1. Resilience

in

the

general

population

News about the coronavirus pandemic is alarming, with an overwhelming number of new cases and fatalities ev-ery day. Governments mandated hard measures of social distancing,quarantineandlockdowns,andbusinessesshut down, highlight the impact andinevitable long-term neg-ative economic and health effects. In addition, although precise estimates of the ﬁnancial damage determined by COVID-19 inEuropeareyetinaccurate,preliminary analy-sesshowthatthedropinthecontinentalGDPwillbe sub-stantial(Fernandes,2020).Undoubtedly,thesearestressful times, particularly since the stressoris new, the absence of warningprecluded preparation and pre-adaptation, no antidotesorvaccinationsbeingcurrentlyavailable,and un-knownlong-termhealthandsociety-relatedimplicationsof the virus.It isunknown howthepandemic willaffect our futurelifestyleandwhenandifwecanresumeourregular lives. This pervasiveuncertainty makesit difﬁcult toplan for the futureand thus generates additionalpsychosocial stress.

The horizonsofourdailylives,ourabilitytotraveland interactfreelyhavesuddenlybeenlimited.Anxietyand dis-tressarenormalresponsestosuchextremecircumstances. Ourstresssystemshaveevolvedtorespondinhighly adap-tiveways,therebyenablinghumanstodealwiththese chal-lenges (de Kloet et al., 2005). While many of us are un-settledandconcernedbythecoronaviruspandemic,weall strivetoadapttothisnewreality.Nevertheless,not every-bodycan successfullydealwithstress andadapt easilyto newcircumstances.Thecurrentpandemicwillaffectsome more than others. Factors inﬂuencing this include living conditions, poverty, poor access to healthcare, illiteracy, uncertainty about thefuture(i.e. risk ofunemployment), genetic background, previous life experiences and social support(SouthwickandCharney,2012).Thus,theimpactof thecurrent pandemic onincidenceandseverityof stress-related disorders will be highly heterogeneous. Scientists andcliniciansworkingintheﬁeldofstressresiliencehave theopportunity todevelop aresearchagendafor examin-ing stress resilience in the general population and in pa-tientcohortsacrossculturesduringthismodernglobal cri-sis.Inaddition,theyalsohavetheobligationtosharewhat isalreadyknownaboutstressresilienceandwhat evidence-basedrecommendationsforboostingmentalresiliencecan help to successfully deal with the coronavirus pandemic (Holmesetal.,2020).

2. Stress

as

a

normal

response

to

the

coronavirus

pandemic

Itshouldbeemphasizedthatdistressandanxietyarenormal reactions toa situation as threatening and unpredictable asthecoronavirus pandemic.Possiblestress-related reac-tionsinresponsetothecoronaviruspandemicmayinclude changesinconcentration,irritability,anxiety,insomnia, re-ducedproductivity,andinterpersonalconﬂicts.Thismaybe

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true for thegeneral population, but particularly apply to moredirectlyaffectedgroups(e.g.healthcarepersonnel). In addition tothe threat by thevirus per se, there is no doubtthatquarantinemeasures,whichareinplaceinmany countries,alsohavenegativepsychologicaleffects,thereby furtherincreasingtheaforementionedstress-related symp-toms.Theseverityofthesesymptomswillatleastpartially dependonquarantinedurationandextent,feelingsof lone-liness,thefearofbeinginfected,(in)adequateinformation, andstigma(Brooksetal.,2020).

Tohelpadaptationtomentalhealtheffectsrelatedtothe coronavirus pandemic, several pieces of advice are avail-able from the rich resilience literature. Promoting social connectedness is of the utmost importance as loneliness andsocialisolationarewhatmakethiscrisisdifferent com-paredtoseveralothers.Moreover,planningroutine day-to-dayactivitiesandpromotingself-care(Kalischetal.,2017). Also,increasedattentionshouldalsobepaidtothe poten-tial role of exercise and nutritionin promoting resilience (Fosteretal.,2017).Inadditiontomaintaininghealthy be-haviors,the WHO alsoadvisetaking regularmedia breaks (WorldHealthOrganization(WHO),2020).Oneofthemost reproducibleﬁndingsinstressandresilienceresearchisthat thehigherthecontrollabilityofastresssituationis,the bet-terindividualscopewiththissituation.Inthecurrentcrisis, itisthereforeofabsoluteessencetohelppeopletofeelin controlandtobeabletoexertcontrolof thesituationas muchaspossible.Therearemanyindividualand evidence-basedmeasuresonecantaketoreducetheriskofinfection andminimizethespreadofthedisease,providingone ex-ample of howpeopleengage inregaining controlof their situation.Althoughthesegeneralstrategieswillworkfora largepartofthepopulation,someindividualsaremore sus-ceptible and exposed tostress than others. Forexample, more vulnerablegroups include peoplewith a psychiatric disorder, healthcareworkers,andpeoplewithlow socioe-conomicstatus.

3. Resilience

in

people

with

a

psychiatric

condition

Thestressemergingfromthesocialdisruptionsand health-related threats in the coronavirus pandemic may be par-ticularly challengingfor individuals withpsychiatric disor-ders.Thegeneraluncertainty,theindividualhealththreat, as well as the quarantine measures may exacerbate pre-existing conditions suchas depression, anxiety, and post-traumatic stress disorder. Moreover, the risk of disease transmissionmayintensifycontaminationfearsinpatients withobsessive-compulsivedisorderandhypochondria,or in-dividualswitha historyofparanoidideation. Even though quarantine measures protectagainstspreading the coron-avirus,theyentailisolationandlonelinesswhichinﬂict ma-jor psychosocialstress andcan possiblytrigger or exacer-batementalillness(Vahiaetal.,2020).Inthisregard, spe-cialattentionshouldbepaidtoolderpeoplesincetheyare themostvulnerableandmorestringentlykeptisolated com-paredtothe restofthecommunity.Feelings ofloneliness in the elderly population maybe worsened by the digital divide, i.e.thegap betweengenerationswhoarefamiliar withinformationtechnologyandthosewhoarenot.

Inabil-itytointeractthroughsmartphonesandcomputersreduces themaintainingofsocialconnection.

Furthermore,usualaccesstostandardmentalhealthcare hasbeen signiﬁcantly disrupted in most countries, poten-tiallydecreasingadherencetopharmacologicaland psycho-logical treatments. Even though long-term mental health consequences may emerge from this pandemic, little is known about whether the current situation will have a negativeeffectonpeoplewithan existingpsychiatric dis-order. As psychiatrists, in contact with outpatients with depression,anxietydisorders,andobsessivecompulsive dis-orders,wehaveobservedbothshort-termdeteriorationand improvement at the symptomatic level. Even though the reasonsforthis heterogeneityofshort-termoutcomesare unknown,patients mayfeelincreased stigmatizationwith socialavoidanceorrejectionasaresult,but,ontheother hand,alsoexperienceincreasedsocialcohesionandsupport fromtheirfriendsandrelatives.

For patients with mental disorders and their care providers,severalsourcesofhelpforcopingwiththe life-stylerestrictionsandothereffectsofthecoronaviruscrisis areavailable,includingthosefromtheRoyalCollegeof Psy-chiatrists,theEuropeanPsychiatricAssociation,the Amer-icanPsychiatricAssociation,andtheInter-agencyStanding CommitteedocumentfromtheWHO).∗Forexample,mental healthcareneedstobeorganizeddifferentlyinresponseto therestrictionsontravelandface-to-facecontactimposed inresponsetothecoronavirusthreat.Multidisciplinary men-talhealthteamsshouldorganizecareandoffer psycholog-icalsupportwithﬂexibilityandcreativity,wherever possi-ble.A telemedicine approachandvarious evidence-based internet-basedinterventions areavailable toallow effec-tiveprovisionatadistance.

4. Resilience

in

healthcare

workers

working

in

the

pandemic

Itshouldberecognizedthatmany healthcareworkersare onthefrontlinesofthecoronavirusoutbreak.Asrecently reported,weshouldnotlosesightofourcolleagues work-ing in emergency or intensive care settings who have to dealwithaheavierandmorestressfulworkloadthanusual (Chenetal.,2020).Thesecolleaguesareexposedto separa-tionfromfamily,unusualsituations,increasedexposureto thecoronavirus,contagionfears,andfeelingsoffailurein thefaceofpoorprognosesandinsufﬁcienttechnicalmeans toassistpatients. Forhealthcareworkers,it willbe chal-lengingtoremainmentallyhealthyintheserapidly evolv-ingsituations, andreduce the risk ofdepression, anxiety, orburnout.Moreover,theyareparticularlyatincreasedrisk for‘moralinjury’whendealingwiththeethicalchallenges ofthecoronaviruspandemic,suchasworkinginconditions withinsufﬁcientresources,situationsoftriage,inadequate palliative care and not being ableto supportrelatives of terminalpatientsadequately(Greenbergetal.,2020). Sev-eralresourcesareavailableforhealthcareworkersand sev-eral strategies recommend, which include team support, stressmonitoring,takingcareofoneself,takingbreaks reg-ularly, and connectingwithothers. Data fromChinahave shown that social and psychological interventions could

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signiﬁcantly enhance healthcareworker well-beingduring theCOVID-19outbreak(Chenetal.,2020).

5. The

need

for

resilience

at

the

societal

level

Itisimportanttorealizethatresiliencedoesnotonlyexist attheindividuallevel,butalsoatthecommunitylevel.In any societal ecosystem, thereis a certainlevel of shared resilienceneededtobeabletoovercomethestressofthe coronaviruspandemicandrecovertonormallevelsof func-tioning. This sharedresilience is vital tofacethe current challengestogether,notonlyatthenationallevel,butalso attheEuropeanandgloballevelwhereallcountriesshould play acrucialsupporting rolebycoordinatingcross-border collaborations. In contrast, nationalism and unilateralism willlikelyincreasethevulnerabilityofasocietytothe cur-rentcoronavirusanditsstress-relatedimpact.

Considering thattherewillprobablybearecurrenceof thecoronavirusinmostcountries,animportantquestionis what the impact will be of the eventual reoccurrenceof the pandemic onmental health of people? Moreover,can thefirstoutbreakinformustobebetterequippedto han-dletheresponsetoasecondorevenmoresubsequent out-breaks?Assuch,itiscrucialtobeawareofstress manage-mentatthesocietallevel.Giventhatpartsofthe popula-tionwithlowersocio-economicstatusarelikelymoreprone tostress-relatednegativeoutcomes,theymaybenefitfrom specific short-termandlong-term resilience enhancing in-terventionsatasocietallevelincludingguaranteeingaccess to online education and information, providing adequate access toeconomic and health infrastructure,stimulating communitiestoorganizethemselves,andtakinginitiatives locally(Lazzarinoetal.,2014).

As a community, we can draw strength from the fact that we areall inthe same generalpredicament andcan take actiontoovercomethissituation,therebygivingusa certain level of control. At the same time,governments, politicians,anddecisionmakersshouldemphasizethefact thatwearenotexposedtoanuncontrollablethreat– nei-ther withrespect to health, norfrom an economic point of view. A good example is the in comparison very suc-cessful approach taken by the South Korean government where thenegative experiences fromprevious pandemics guidedfastandeffectiveactions,leadingtoamore effec-tive controlof thecurrentpandemic.Governments should provide quick and accurate information that can be eas-ily and reliably interpreted by all the individuals of the community, not only by experts.The communication pro-cess is thus critical topromote understanding of the po-tential risksand ofthe strategiestoavoid them;this will increaseperceivedcontrolandlikelyreducethe psychoso-cialstressimposedbythecoronavirusoutbreak.Thereare also immediate, direct, and powerful measures that can be taken to counteract the negative effects of the coro-navirus pandemic for mental health. Ensuring clear and consistent communicationfromgovernmentbodies, scien-tiﬁc organizations and mental health providers, and pro-viding funds for those individuals in the general

popula-tion without work couldall help. These measures are es-sential toactively deal withthecrisis, increasing individ-ualandcommunityresilienceandminimizingthenegative impactonoursociety.

6. Resilience

in

times

of

the

coronavirus

pandemic:

a

way

forward

Many questions remain about how resilient we can be in the face ofthe coronavirus pandemic. Even though there is no final answer, we anticipate that science will pro-vide guidanceina timewhere validscientificinformation is sorelyneeded (Holmes etal., 2020). Severalinitiatives havebeeninitiatedtogainmoreinsightintotheshortand long-term psychosocial impact of the COVID-19 pandemic in the general population, patients with psychopathology and healthcareworkers, includingdetailedquestionnaires acrossEurope.Weencourageconsortiaworldwideto com-binetheir resources andstrategicapproachtoobtain and sharevalidandmeaningfuldataonhigh-riskfactorsand re-silience mechanismsrelating tomental health in this cri-sis. This will help guide our approaches toprevention as wellastreatmentforvariousgroups.Itwillalsobe impor-tanttoobtaindataonthepsychosocialimpactinacuteand recoveredCOVID-19patientsandtheirrelativesonhowto bestmitigatethenegativeeffects.Suchstudieswillallow theidentificationoffactorsassociatedwithresilience, ac-cording toliving context, coping strategies, personal his-toryand,ifpossible,biologicalfeaturessuchas(epi)genetic background.Thiswillprovideaplatformfromwhichto de-velopcommunityandpersonalizedinterventionstoimprove resilienceandreducetheriskofpsychopathologyinthe cur-rentandsimilarcrisesinthefuturestresschallenges.

Inconclusion,wenotonlyadvocateforanincreased fo-cusonmentalhealthduringthecoronaviruspandemic,but wealsohighlighttheurgentneedofaugmentingourfocus onresilienceand onstrategiestoenhanceit asresilience ispivotaltocopewiththestressimposedbythevirus out-breakattheindividualandsocietallevel.

∗

https://www.psychiatry.org/psychiatrists/covid-19-coronavirus

https://www.europsy.net/covid-19-resource-centre/ https://www.rcpsych.ac.uk/about-us/

responding-to-covid-19

https://www.who.int/docs/default-source/coronaviruse/ mental-health-considerations.pdf

CRediT

authorship

contribution

statement

ChristiaanH.Vinkers:Conceptualization,Writing- orig-inal draft, Writing - review & editing. Therese van Amelsvoort:Conceptualization,Writing-review&editing.

JonathanI. Bisson:Conceptualization,Writing- review& editing.Igor Branchi: Conceptualization,Writing - review & editing.JohnF. Cryan:Conceptualization,Writing- re-view & editing. Katharina Domschke: Conceptualization, Writing -review & editing.OliverD. Howes: Conceptual-ization,Writing-review&editing.MirkoManchia: Concep-tualization, Writing- review & editing.Luisa Pinto:

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Con-ceptualization, Writing -review & editing.Dominique de Quervain: Conceptualization, Writing - review & editing.

MathiasV.Schmidt:Conceptualization,Writing-review& editing.NicJ.A.vanderWee:Conceptualization,Writing -review&editing.

Role

of

Funding

Source

Noroleoffundingsource.

Contributions

CVwrotetheﬁrstdraft.Allauthorsprovidedcriticalinput andrevisions.

Conﬂictofinterest

Allauthorsdeclarenoconﬂictofinterest.

References

https://www.who.int/docs/default-source/coronaviruse/ coping-with-stress.pdf.

Brooks,S.K.,Webster,R.K.,Smith,L.E.,Woodland,L.,Wessely,S., Greenberg,N.,Rubin,G.J.,2020.Thepsychologicalimpactof quarantineandhowtoreduceit:rapidreviewoftheevidence. Lancet395,912–920.

Chen, Q., Liang,M., Li, Y., Guo, J., Fei, D., Wang,L., He, L., Sheng,C., Cai, Y., Li,X., Wang, J., Zhang,Z., 2020. Mental healthcareformedicalstaff inChinaduringtheCOVID-19 out-break.LancetPsychiatry7,e15–e16.

deKloet,E.R.,Joels,M.,Holsboer,F.,2005.Stressandthebrain: fromadaptationtodisease.Nat.Rev.Neurosci.6,463–475. Fernandes, N., 2020. Economic effects of coronavirus outbreak

(COVID-19) on the world economy SSRN: https://ssrn.com/ abstract=3557504 orhttp://dx.doi.org/10.2139/ssrn.3557504

Foster,J.A.,Rinaman,L.,Cryan,J.F.,2017.Stress&thegut-brain axis: regulation by the microbiome. Neurobiol. Stress 7, 124–136.

Greenberg,N.,Docherty,M.,Gnanapragasam,S.,Wessely,S.,2020. Managingmentalhealthchallengesfacedbyhealthcareworkers duringcovid-19pandemic.BMJ368,m1211.

Holmes, E.A., O’Connor, R.,Perry, V.H., Tracey, I., Wessely, S., Arsenault,L.,Ballard,C.,Christensen,H.,Silver, R.C.,2020. MultidisciplinaryresearchprioritiesfortheCOVID-19pandemic: a call foraction formental health science. Lancet Psychia-trydoi:10.1016/S2215-0366(20)30168-1, Availableonline 15th April.

Kalisch,R., Baker,D.G., Basten, U., Boks, M.P., Bonanno, G.A., Brummelman,E.,Chmitorz,A., Fernandez,G.,Fiebach,C.J., Galatzer-Levy, I., Geuze, E., Groppa, S., Helmreich, I., Hendler,T.,Hermans,E.J.,Jovanovic,T.,Kubiak,T.,Lieb,K., Lutz,B.,Muller,M.B.,Murray,R.J.,Nievergelt,C.M.,Reif,A., Roelofs,K.,Rutten,B.P.F.,Sander,D.,Schick,A.,Tuscher,O., Diest, I.V., Harmelen, A.V., Veer, I.M., Vermetten, E., Vinkers,C.H., Wager,T.D., Walter,H.,Wessa,M., Wibral,M., Kleim,B.,2017.Theresilienceframeworkasastrategyto com-batstress-relateddisorders.Nat.HumanBehav.1,784–790. Lazzarino,A.I.,Yiengprugsawan,V.,Seubsman,S.A.,Steptoe,A.,

Sleigh, A.C., 2014. The associations between unhealthy be-haviours,mentalstress,andlowsocio-economicstatusinan in-ternationalcomparisonofrepresentativesamplesfromThailand andEngland.Global.Health10,10.

Southwick,S.M.,Charney,D.S.,2012.Thescienceofresilience: im-plicationsforthepreventionandtreatmentofdepression. Sci-ence338,79–82.

Vahia, I.V., Blazer, D.G., Smith, G.S., Karp, J.F., Stef-fens,D.C., Forester,B.P., Tampi,B.,Agronin,M., Jeste,D.V., Reynolds, C.F., 2020. COVID-19, Mental Health and Aging: a NeedforNewKnowledgetoBridgeScienceandService.Am.J. Geriatr.PsychiatryInPress.

Zhou,F.,Yu,T.,Du,R.,Fan,G.,Liu,Y.,Liu,Z.,Xiang,J.,Wang,Y., Song,B.,Gu,X.,Guan,L.,Wei,Y.,Li,H.,Wu,X.,Xu,J.,Tu,S., Zhang,Y.,Chen,H.,Cao,B.,2020.Clinicalcourseandrisk fac-torsformortalityofadultinpatientswithCOVID-19inWuhan, China:aretrospectivecohortstudy.Lancet.