Objectives: To describe lessons learned during the first COVID-19 outbreak in developing urgent interventions to strengthen healthcare workers’ capacity to cope with acute stress caused by health care pressure, concern about becoming infected, despair of witnessing patients’ suffering, and critical decision-making requirements of the SARS-CoV-2 pandemic during the first outbreak in Spain. Methods: A task force integrated by healthcare professionals and academics was activated following the first observations of acute stress reactions starting to compromise the professionals’ capacity for caring COVID-19 patients. Literature review and qualitative approach (consensus techniques) were applied. The target population included health professionals in primary care, hospitals, emergencies, and nursing homes. Interventions designed for addressing acute stress were agreed and disseminated. Findings: There are similarities in stressors to previous outbreaks, and the solutions devised then may work now. A set of issues, interventions to cope with, and their levels of evidence were defined. Issues and interventions were classified as: adequate communication initiative to strengthen work morale ; resilience and recovery from physical and mental fatigue ; reinforce leadership of intermediate commands (informative leadership, transparency, realism, and positive messages, the current state of emergency has not allowed for an empirical analysis of the effectiveness of proposed interventions. Sharing information to gauge expectations, listening to what professionals need, feeling protected from threats, organizational flexibility, encouraging teamwork, and leadership that promotes psychological safety have led to more positive responses. Attention to the needs of individuals must be combined with caring for the teams responsible for patient care. Conclusions: Although the COVID-19 pandemic has a more devastating effect than other recent outbreaks, there are common stressors and lessons learned in all of them that we must draw on to increase our capacity to respond to future healthcare crises. The rapid spread of the COVID-19 pandemic and the adverse conditions in which health care was initially carried out affected healthcare institutions’ teams’ wellbeing and work morale. They have led to acute stress reactions among health professionals, specifically increased intensity during that first outbreak ,3. This The overload caused by the rapid increase of cases, the uncertainty about their clinical outcome, and the emotional impact of seeing a significant number of patients dying , added to the constant changes in instructions, the break in the supply chain, or the fear of catching (or taking home the SARS-CoV-2) impacted the emotional balance of professionals. This impact is now becoming more evident as new data emerges ,5,6.Although healthcare professionals are used to acute stress derived from attending their duties during complex procedures worldwide, their physical and mental overload and effort have been very uneven . There hThe experience of previous outbreaks, together with intervention efforts being communicated, initially through social networks and other informal channels, and subsequently in scientific forums, led to proposals that sought to mitigate the psychological impact COVID-19 patient care had on institutions, staff and healthcare workers . The appIn the first wave, Spain was one of the countries where the incidence of COVID-19, mortality and the number of healthcare providers infected were higher. The alarming growth of discouraged professionals compromised the care of COVID-19 patients, fueling the creation of our task force. It was activated on 11 March 2020, following the first observations of acute stress reactions among healthcare professionals in Spanish hospitals and primary care centers. On that date, the number of confirmed patients with COVID-19 was 9801, and there had been 196 deaths. Five days later, a total of 47,800 cases and 1532 deaths had been recorded, exceeding the capacity of a growing number of professionals to cope with stress. During the first outbreak near a quarter of COVID-19 patients were healthcare workers . This adIn Spain and different countries and institutions worldwide, interventions had to be implemented quickly to address this challenge and ensure that professionals found sufficient support to care for patients. These interventions were designed based on interventions in other health crises, in emergencies, and by combining different strategies adapted to the changing needs of the moment. The urgency of the moment made it necessary to take decisions and propose alternatives that were not known to be effective in this pandemic but had proved useful on previous occasions. Early reports were that professionals were becoming discouraged and that compassion fatigue, moral conflict, fear, material shortages and acute stress reactions were beginning to affect their ability to care for COVID-19 and other patients . The timThe main objective of this study is to describe the lessons learned during the first COVID-19 outbreak in the development of urgent interventions to strengthen healthcare workers’ capacity to cope with acute stress caused by health care pressure, critical decision-making requirements, concern about becoming infected, despair of witnessing patients’ suffering and the perception of seeing limited their ability to perform the task properly during the first outbreak of the SARS-CoV-2 pandemic in Spain. It includes a description of our approach and experience to share and reflections to better prepare for future crises. This intervention had a two-step approach. Firstly, recurring issues were analyzed. Secondly, appropriate interventions were identified to address each of them. This study combined a pragmatic literature review to identify and select impacts due to previous outbreaks and the implemented interventions to face. Moreover, a qualitative approach to collect data from several healthcare institutions from all over the country to identify the impact dues to caring for COVID-19 patients, undermining work morale and responsible for the acute stress experienced by healthcare personnel. Finally, the working group applied the consensus conference technique to agree upon brief interventions to address acute stress considering the level of evidence of the recommendations, following SIGN guidelines . They shTo provide resources to strengthen the capacity of hospital and primary care healthcare professionals to restore work morale and cope with the acute stress experienced during the first wave of the COVID-19 pandemic. These interventions should be accepted and easily accessible for healthcare professionals. They should also be simple, self-applied, not time-consuming, and reach as many professionals as possible. Given the urgency, diversity of situations and personal experiences, these resources were designed to be available and used according to the needs of each moment and professional.Studies have identified higher acute stress among healthcare professionals of specific departments caring directly for COVID-19 patients . The mosAt the beginning of March 2020, the Spanish research group on second victims was invited by several hospitals to propose interventions to give emotional support to healthcare professionals in whom symptoms of distress are already observed. This group had experiences in supporting interventions for professionals who had been involved in a safety incident with severe consequences for patients , made upBarriers and strengths that would facilitate the dissemination of the approach and consensus recommendations for strengthening work morale and coping with acute stress were analyzed.An express review of published studies on the impact on healthcare professionals of previous pandemics, care of patients in terrorist attacks and natural disasters, and interventions to cope with these situations was conducted.In parallel, a consensus was reached on common problems during the COVID-19 pandemic in hospitals or primary care. Also, to identify proposals to minimize this impact on healthcare professionals.The following databases were searched: ProQuest, Science Direct, Scopus, and MEDLINE. MeSH terms mental health, wellbeing, healthcare personnel, outbreak, and COVID-19 were combined by the Boolean operator AND (restricted terms to title and abstract) to localize references published in English and Spanish until March 2020. Google and Google Scholar and preprint archives were searched using key phrases in line with the search strategy. Lastly, grey literature and hand searching was employed as sources of information. Eligibility criteria included research conducted within the COVID-19 outbreak context, describing the impact. Exclusion criteria included studies on the general population’s impact on patients or groups other than health professionals.VPJ, IC and MG read the titles and eliminated duplicates. After reading abstracts, relevant studies were retained, and the rest were discarded. A fourth researcher (JJM) resolved disagreements to assess the relevance of the studies. A description was made of the problems identified and the interventions to address them in each study. The following categories were established to extract information from each of the studies considered relevant for this study: the challenge to be addressed, country, year, target population, sample size, type of intervention, results. Mendeley and Excel were used to manage the references analyzed and share the information among the team members.The Appraisal tool for Cross-Sectional Studies (AXIS tool) was used to assess published studies about the impact of the previous and current outbreak . AXIS coThe narrative synthesis approach was used. Key findings responding to essential questions defined previously by the research team were considered describing current understanding.The 28 members of the Core Group .Thirteen healthcare institutions from eight autonomous communities in Spain.Using the previous literature review analysis, categories were identified and generated to prepare structured questions to understand better and collect data in Spanish healthcare institutions. The most common problems were identified in terms of inability to cope with the situation, damage to work morale, breakdown of work teams, and psychological disturbance. Subsequently, a qualitative approach was used to capture professionals’ experiences in 12 primary care centers and 13 hospitals. Each of the Core Group members led their respective teams and were responsible for collecting the most relevant problem situations and sharing with the rest of the partners. Structure content analysis was used to code the information provided by the core group members regarding the impact of the outbreak. JJM, MG and IC made integration and coding of verbatims in a dataset to share this information among the members of the Core Group, who contributed to identifying the most common problems and their origins. All the nuances and experiences were consolidated in a table using Excel. This dataset was shared using e-mail and WhatsApp applications. Ideas were grouped as the information became saturated (spontaneity and consistency among the different informants). Based on the classification of the information in the categories of analysis, a second round was made incorporating possible interventions carried out from the experience of the core group members to respond to the problem situations raised. First, for each coded problem in categories, the core group, guided mainly by mental and occupational health experts’, suggested specific interventions. Second, these interventions linked to identified problems were adapted to the current context demands. Barriers that could prevent or facilitate the implementation of these interventions and the expected benefits were also analyzed. Third, each core group member received all the information and assessed the adequacy of the proposed interventions, their feasibility and acceptability by the healthcare workers in their respective institutions. Also, produced feedback to improve the interventions considering the proposals collected. Fourth, the selection of interventions considered the available evidence and the successive feedback produced by healthcare workers in each institution participating in this study to improve these interventions before dissemination. Professionals with expertise in the development of audiovisual materials collaborated in this task. After successive reviews, the agreement among members of the core group determined the recommended resource proposals to address the demands caused by the pandemic.Lastly, the interventions were classified according to the study design. SIGN  was usedhttps://segundasvictimascovid19.umh.es/p/inicio.html [The support resources were disseminated on the website cio.html . As an oParticipants shared their experience in developing, disseminating, and implementing these interventions. They participated in successive rounds using e-mail to redefine them and establish lessons learned. The consensus among the core group members was obtained once the saturation of the ideas was achieved.None of the members of the working group had any significant conflicts of interest. Decisions were made independently and without influence or interest from outside the public service.A total of nine references describing the experience of health professionals caring for patients with COVID-19, three reviews studies healthcare workforce distress in previous outbreaks, and two studies regarding professionals’ reactions after caring for victims of natural disasters were identified . SupplemManaging the uncertainty of caring for patients whose condition is not well understood, the fear of becoming infected and then infecting loved ones, or the reluctance to seek help have been described in previous studies and among professionals in China during the first outbreak of the new coronavirus. Also, the feeling of being rejected and stigmatized by neighbors due to fear of infection and doubts about whether they have sufficient preparation and training to face this situation was mentioned. Anxiety, affective symptoms, feeling exhausted, burnout, insomnia, increased aggressiveness in interpersonal relationships, loss of interest in daily activities, and psychosomatic symptoms are frequent . In general, nurses report more significant distress than physicians. Feeling responsible for patient outcomes (sense of involvement in the task), more even leadership styles, and receiving continuous feedback from managers on the outbreak’s evolution and how things are going help minimize the impact. The qualitative study identified problem situations in the different participating Spanish hospitals. Three main categories were coded: organization, human and material resources; training and information gaps; and individual affective response. Following these categories, interventions were designed in six areas Organization, Human and Material Resources, Human Factor, Environmental and pandemic-specific stressors, Fear or Panic Reactions, Critical Decision-Making Regarding Health Care Issues, and Post-Crisis.A set of 16 interventions were proposed. These interventions have proven effective in situations sharing some similarities but are, in essence, different from those motivated by the SARS-CoV-2 pandemic. These actions have been established with the consensus of the work team . The situation’s urgency has not allowed us to establish an empirical analysis of its effectiveness or identify which measure elements are keys to the outcome.The first group of interventions aimed at strengthening work morale . The secSituations identified as the main causes of distress for the healthcare professional during the outbreak are summarized in Box 1ORGANIZATION, AND HUMAN AND MATERIAL RESOURCES:  Receiving rapidly changing instructions (unclear task assignment), coupled with inconsistencies in the chain of command. Infra-utilization or misuse of all health resources due to lack of coordination. Lack of epidemic management protocols.  Realizing that patients with other pathologies other than COVID-19 do not receive the care they need.  Mandatory triage systems and forceful rash decisions are reserved for situations of major disasters with a high component of ethics conflict. There has been a transfer of decisions with ethical content to professionals.  Reduced human resources due to the loss of professionals with a high risk of exposure.  Dissolution of consolidated work teams.  Scarcity of adequate materials and supplies (according to centers and services) to alert to or provide protection against biological risk  and disruption of the supplies chain (according to centers and services).TRAINING AND INFORMATION GAPS:  Working in unusual healthcare environments without receiving appropriate training, usually due to abrupt incorporation into or transfer to new and/or more complex environments.  Lack of training and confusing information on protective measures for the professional’s family members of professionals and on measures to isolate patients in the home to prevent contagion.INDIVIDUAL AFFECTIVE RESPONSE:  Irritability, especially when imprudent behavior was observed in patients or their companions and when facing fatigue-induced failures, emotional overload, or inability to concentrate on the task.  Feeling powerless when patients in fear of being sick with COVID-19 are isolated and, in some cases, die in solitude.  Being emotionally overwhelmed without daring to share this experience with others.  Fear of infecting the family and/or relative and close friends.The Ser+Contra COVID app was externally evaluated and accredited with the Andalusian Health Quality Agency’s Healthy App distinction . FinallyAt first, there was resistance among professionals to recognize their personal experience, which, together with the lack of information on identifying signs of acute stress and dealing with these situations, hindered access to support resources. As a result of the daily pressure experienced in the centers and the effect of the media and social networks drawing attention to the workload and acute stress reactions among healthcare professionals, this situation gradually changed.The factors that may have facilitated the implementation of the recommendations were mainly motivated by the alarming situation experienced in the centres. The dissemination of the website in social networks, press, TV and radio also helped. Dissemination employing successive webinars  and the information on the website of second victims of patient safety incidents, which brings together some good news sections and the active role of professionals on the social networks, contributed to its dissemination.Between 31 March and 13 April, 43,907 visits were recorded. In the following months, the developed resources were also applied in several Latin American countries.At the time when the support resources for professionals were designed, society considered them to be heroes. Once the confinement ended, as the incidence of the first outbreak decreased, this social valuation dissipated, and the number of disputes over the care (or lack of care) given to COVID-19 and non-COVID-19 pathologies increased. Although we contemplated this possibility among the precautions for the post-crisis, we did not identify appropriate resources to deal with this situation.The prediction of a return to normality announced by the health authorities has not been fulfilled. Unlike other outbreaks , the COVID-19 pandemic continues over time with different outbreaks and in very different ways depending on the territory. This causes the adaptation responses of professionals to change, and new affective reactions may appear, together with burnout and disenchantment with the organization. Adding to the risk of infection for the professionals’ families and themselves, this circumstance also makes the situation different concerning other situations such as multiple accidents, natural disasters, or terrorist attacks with numerous victims. The resources we proposed were selected for the specific situation experienced in March and April in healthcare centres in Spain and may not have the same usefulness at other times with a different social environment and work morale in healthcare centres.We did not identify in our initial analysis that administrative bureaucracy would negatively affect work morale. Even though protocols and processes in the clinical setting have been modified in a matter of hours, organisational processes have not had the same agility of adaptation, negatively impacting professionals’ confidence in the health system.Departments that require specific training, such as critical care units, that under normal conditions we find a majority of highly qualified professionals (A), some professionals with average experience (B) and few new professionals with no previous experience (C). At the beginning of the outbreak and because of the number of professionals initially infected  or in iAt the end of their shift , the professionals wanted to leave the center as soon as possible. This aspect was not adequately assessed at the beginning. No activities outside the healthcare centers were devised.One of the support resources that we have identified later is that the professionals value positively to see responsible behaviors to avoid infection among the citizens. This has become more evident in successive waves.There has been a continuous oversaturation of information, both in quantity and diversity of sources and with too much “noise”. Fake news appeared quickly, and although we cannot determine its effect on professionals, this work could be considered in the future by occupational health services as another disruptive factor. In addition, the increasing number of negative news in all media influenced the morale of professionals, an aspect that we did not initially take into account.Information oversaturation also stemmed from the amount of information that was quickly generated on the impact of COVID-19 patient care on the wellbeing of professionals and a growing and disorganized proliferation of suggestions and recommendations. In our case, we sought to simplify the information  since we understood that an expansion of news and information channels produces misinformation.Uncertainty and complexity have continued, and it has been necessary to accept the continuous changes in the protocols and rules of action. Even months after the pandemic, this situation persists, and the teams have learned to tolerate uncertainty and make decisions in this context. This aspect was not initially appreciated and is likely to have been one of the success factors of the teams in dealing with the pandemic.Keeping staff informed about the evolution of the pandemic, the availability of equipment and resources, organizational changes and the reasons for them have been another success factor.In this crisis, we have seen teams that have been able to draw strength from where there seemed to be nothing, overcoming adversity. Clinical leadership has made a difference in the organizational and technical capacity of healthcare organizations. This aspect requires further attention in the future to leverage the advantage it represents for healthcare organizations, probably also after this healthcare crisis is over.Organizational flexibility and the versatility of the different specialties to perform tasks other than their usual ones  should be assessed to see whether it has been a protective factor for professionals to the solidarity it represents.The need for information has meant that other high-risk sources have replaced traditional sources of evidence due to the lack of critical evaluation . The use of non-conventional means of scientific communication has been indispensable, although it entailed a greater risk for patient safety.Traditional measures to determine the effectiveness of interventions have given way to others based on visits to a web page, downloads of health apps, among others. The time available was too short to use traditional outcome assessment models. In this sense, methods already relegated, such as action-reaction, have regained their usefulness at the onset of this health crisis.The combination of social alarm, services over-saturation, scarcity of resources, and torpid evolution of patients by COVID-19 has made health professionals suffer acute stress, limiting their wellbeing and, in some cases, moral damage ,4,41.In Spain, during the first outbreak a large number of health professionals experienced confusion, frustration, fear, hopelessness, and doubts regarding their abilities and those of the healthcare system . In someIn addition to the already known concerns regarding mechanical ventilator and medication shortage, and the fear of infecting family members, this study highlights other issues. Primary care has seen its work dynamic broken and has had to adapt quickly to a completely different care environment for which it was not prepared. The mortality among older adults living in nursing homes has exceeded all estimations . The numThe acute stress reactions that have been registered have been considered that could progress to anxiety-depressive syndromes and post-traumatic stress . NeverthSecondary prevention is crucial to guarantee enough workforce to deal with the return to normality . This wiThese recommendations have supported frontline professionals caring for COVID-19 patients, maintaining labor morale and reducing the immediate and foreseeable medium-term emotional impact and overload. The number of visits to the website exceeded 110,000 by the end of 2020. This approach supporting frontline practitioners has been urgently needed and has been similar in many countries . The sucThe conventional pattern when a catastrophe occurs is that after the impact, work morale is rebuilt, and emotional equilibrium is restored as the source of stress ceases . This waAnother relevant aspect, to which less attention has been given, is that the professionals’ confidence was a necessary factor to boost the morale of society at a critical moment. The population needed to see the professionals in place and control of the emergency. Our group identified this aspect in the early phase of the pandemic when the decision was made to quarantine the population.These interventions have been proposed by the centers participating in this tasks force, reflecting their experience. Their feedback has been used to improve recommendations regarding this matter. The results of this proposal were disseminated on a specific website . The main limitation of this study is that the effectiveness of each of these interventions for the purpose for which they have been applied has not been contrasted through experimental or quasi-experimental studies. The quickness of extraction from data sources may have limited access to other relevant references. In this context, a detailed analysis was spared for the immediacy of decision-making. Although coinciding with those described in other countries, the identified stressors were very uneven in intensity in the different territories, making it difficult to assess whether a generalist intervention would be appropriate. Undoubtedly, lessons have been learned as the pandemic progresses, but we still have work to do. There are personal differences that have led healthcare workers to desert their jobs or even decide to work in the front line of the pandemic; possible underlying reasons are not yet known. Health systems and, in particular hospitals are very hierarchical structures, as has already been exposed in other studies . It is nAs Shanafelt et al.  have poiThe emotional impact of this health crisis has been in some respects like that of previous outbreaks. The fear of becoming infected and/or infecting family members, the resistance to receive help, the reluctance to ask for support or the anxiety and affective disorders that have been experienced have many similarities. On the other hand, the moral damage caused by the loss of patients due to the scarcity of resources or the value of peer support in this new crisis has some different characteristics from previous outbreaks. The experiences of previous outbreaks have not led to the adoption of interventions to train professionals to face new crises. In this pandemic, some of the experiences have been repeated. This situation must be avoided from now on.The involvement of occupational health departments has been essential, and in our case, it has been especially useful to incorporate their knowledge of the experience being lived in the centers. In the recovery phase, these departments should be reinforced to pursue improvements in occupational wellbeing. In this outbreak, we have observed that the interventions that have encouraged more participative leadership styles, the organizational culture that facilitates interdisciplinary teamwork and the feedback of information provided by middle managers and supervisors have been positive in minimizing its impact. The focus of supporting interventions should not be only on workers as individuals but also on the team in which they are integrated. In our case, interventions were proposed to strengthen the morale of the group. This aspect could be reinforced to face new health crises in better conditions.The briefing techniques and those reinforcing peer support were the most accepted by the professionals. Feeling that the institution is concerned about their welfare is another factor that favored facing the impact of the pandemic. Examples of high demanding interventions were recommendations related to protocols when arriving home to avoid contagion. Helping isolated patients maintain contact with their families. And how they could maintain contact with their young children when they chose to live in a hotel for professionals or when the professional was in isolation due to infection or close contact.Although the COVID-19 pandemic has a more devastating effect than other recent outbreaks, there are common stressors and lessons learned in all of them that we must draw on to increase our capacity to respond to future healthcare crises.


Background: Evidence of the effectiveness of intervention against extreme heat remains unclear, especially among children, one of the vulnerable populations. This study aimed to evaluate the effectiveness of a primary school-based intervention program against heatwave and climate change in China to provide evidence for development of policies for adaptation to climate change. Methods: Two primary schools in Dongtai City, Jiangsu Province, China, were randomly selected as intervention and control schools (CTR registration number: ChiCTR2200056005). Health education was conducted at the intervention school to raise students’ awareness and capability to respond to extreme heat during May to September in 2017. Knowledge, attitude, and practice (KAP) of students and their parents at both schools were investigated by questionnaire surveys before and after intervention. The changes in KAP scores after intervention were evaluated using multivariable difference-in-difference (DID) analysis, controlling for age, sex, etc. Results: The scores of knowledge, attitude, and practice of students and their parents increased by 19.9%  and 22.5% ; 9.60%  and 7.22% ; and 9.94%  and 5.22% , respectively, after intervention. The KAP score changes of boys were slightly higher than those of girls. Older students had higher score changes than younger students. For parents, the higher the education level, the greater the score change, and change in scores was greater in females than in males. All the health education activities in the program were significantly correlated with the changes in KAP scores of primary school students after intervention, especially those curricula with interesting activities and experiential learning approaches. Conclusions: Heat and health education program in primary school was an effective approach to improve cognition and behavior for both students and their parents to better adapt to heatwaves and climate change. The successful experience can be generalized to respond to the increasing extreme weather/climate events in the context of climate change, such as heatwaves, and other emergent occasions or public health education, such as the control and prevention of COVID-19. Global climate change, with increased frequency, intensity, and duration of extreme heat events, has and will continue to lead to more morbidity and mortality of heat-related diseases and injuries . It was Extreme heat has become one of the main causes of deaths in many regions . Many epHeat-related illnesses are preventable to some extent. Prompt and effective implementation of adaptation actions will protect human health from the effects of heat waves. Intervention strategies that focus on addressing threats of heat waves have been implemented in many countries, especially in North America, Europe, Australia, and parts of Asia ,14. The To provide scientific evidence for local health and education authorities for adaptation to extreme heat among school children, we implemented a primary school-based intervention program to improve knowledge, attitude, and practice (KAP) related to extreme heat among school children, and evaluated the effectiveness of the intervention in Dongtai City, Jiangsu Province, China. We hope the findings can have policy implications for other countries and regions with similar climatic situations.We performed a primary school-based intervention study in Dongtai City, which is located in the central coastal area of Jiangsu Province in China, at 120°07′~120°53′ east longitude and 32°33′~32°57′ north latitude, with a total area of 3175.67 square kilometers and a permanent resident population of proximately 980,000. It belongs to the subtropical monsoon maritime climate, and has four distinct seasons with cold winters and hot summers. The annual average temperature is 15.0 °C in Dongtai.Two primary schools located in two communities with similar economic and education levels were selected in Dongtai on the basis of their willingness to participate. One school was randomly chosen as the intervention school and the other one as the control school. Considering their understanding ability, all the students from the third to the fifth grades at each school were chosen as the study population. In addition, the parents of these students were also invited to participate in this study.A series of health education activities were carried out at the intervention school to raise the primary school students’ awareness of and ability to respond to climate change and heatwaves from May to September in 2017 . The maiA structured questionnaire was used to assess the knowledge, attitude, and practice of both students and their parents in the adaptation to extreme heat and climate change. The pre- and post-intervention questionnaire surveys were carried out in May and October 2017, respectively. Each questionnaire survey was performed simultaneously at the intervention and control schools, for both primary school students and their parents. Each participant signed a written informed consent before each survey.The answers to each question in the questionnaire were scored quantitatively see . The fulEthical approval for this study was granted by the National Institute of Environmental Health, Chinese Center for Disease Control and Prevention . This project has been registered in Chinese Clinical Trial Registry (Registration number: ChiCTR2200056005).Y represents the dependent variable, that is, the KAP score. ε is the random error term.Difference-in-difference (DID) analysis is a popular method to evaluate the effectiveness of interventions ,19,20. IIn order to compare the score changes among knowledge, attitude, and practice, we assigned a new indicator through a DID estimator divided by the full marks of each item, which was the standardized percentage of the increased scores.t-test and chi-square test were used to determine the homogeneity of study subjects between the intervention and control schools for the descriptive analysis, and to compare the KAP scores between different groups. Spearman correlation analysis was conducted to assess the correlations between KAP score changes after intervention and health education activities of the students at the intervention school, in order to identify the more effective intervention measures.The All the statistical analysis were performed using SAS9.4 .The essential information of the primary school students was collected before and after intervention, as shown in A total of 1264 parents were investigated at the two schools before and after intervention . The ageIn terms of knowledge, the scores for cognition of heat waves, high temperature warning, and hot weather definition increased the most, by 44.7% , 34.2% , and 33.4% , respectively. The scores for the awareness of climate change adaptation measures and heatstroke treatment measures increased 14.9%  and 13.8% . The relatively low change level for awareness of climate change and its health effects suggested that relevant education contents in the health education curriculum should be improved in future intervention campaigns.For attitude and practice, the scores for willing to learn relevant knowledge and paying attention to weather forecasts increased relatively more, by 11.9%  and 14.8% , respectively.The age-specific KAP score changes (DID estimator) after intervention for the primary school students at the intervention school compared with the control school are shown in In order to further evaluate the relationship between various health education activities and KAP improvement among primary school students, and to explore better intervention methods, Spearman correlation analysis was conducted between the changes in KAP scores and the participation in various health education activities at the intervention school. The results are shown in Among the students that completed the questionnaire survey at the intervention school during the endline, 58.0% answered that they could obtain medicine to prevent heatstroke at the school clinic when they felt unwell during hot days. A share of 87.0% of the students believed that participating in these activities was helpful to increase their knowledge of climate change and health impacts, and 87.6% of the students indicated that they would be willing to participate in such activities again, indicating the impacts and effectiveness of the intervention activities.p < 0.0001). However, the sex difference was not statistically significant (p = 0.0783).The analysis of the differences in the age and sex ratio among students participating in different numbers of activities  demonstrThe KAP scores for parents of primary school students at the intervention and the control schools before and after intervention, and the results of the DID analysis of score changes, are shown in We assessed the effectiveness of implementing health education intervention program on climate change and health adaptation through a primary school-based intervention study in China using difference-in-difference (DID) analysis. The results indicated that not only the primary school students but also their parents had significantly improved the cognition of extreme heat and health adaptation.To the best of our knowledge, this is the first primary school-based intervention program on improving KAP to adapt to extreme heat in China. Xu et al. performed a community-based intervention during heat waves to improve knowledge, attitude, and practice in Jinan, China . AnotherWe set up a standardized percentage of increased scores to facilitate comparison of the score changes among items. The itemized results of attitudes and practices of primary school students showed that changes in attitudes and behaviors were smaller than the improvement in knowledge. Smaller changes in attitude and practice scores may be because changes in attitude and behavior require more intensive and long-term education than the change in knowledge. Another possible reason may be associated with higher baseline scores due to the items being common questions or behaviors that most participants already performed , such asWe found greater changes, in particular, in knowledge and attitudes among older primary school students. For appropriate practice, however, score changes increased with age until 11 years old. This might may be because older students have higher capacity of knowledge acceptance, but find it difficult to easily change their behaviors once their own habits have been developed when reaching some certain age. It was further suggested that more efforts should be made to transfer knowledge to behavior change, and improving pupils’ behaviors or helping them develop good habits in future interventions. Schools have the best opportunity to develop curricula that prepare students for the anticipated changes to adapt to heat waves and climate change . Our finIt is notable in this study that we also evaluated the influence of implementing intervention in primary school students on the KAP of their parents. The results showed that the KAP, especially for knowledge items, of parents on heat waves and health were also significantly increased after implementing intervention for their children at the intervention school. It was found that the improvement in children’s cognition can promote parents’ awareness and cognition, and parents as the closest caregiver can, in turn, influence and improve children’s cognition, and urge children to develop good behavior, thus forming a virtuous circle. Strengthening health school programs is urgently needed to strengthen a country’s capability to successfully cope with the effects of climate change, according to a study on global health . The sucAll the health education activities in the program were significantly correlated with the changes in the KAP scores of primary school students after intervention. It was found that the health education activities had great impacts on the improvement and change in the relevant knowledge, attitude, and practice of primary school students. This was particularly the case of the health education curricula that included interesting activities, such as listening to lectures/watching cartoons, and experiential learning that can explore the activeness of students, such as broadcasts between classes, hand-copying newspapers, and speech contests. Curriculum and experiential learning approaches have also been proved to be effective strategies in nutrition health education of elementary school students . Our resWe found the scores for most of the items of attitude and practice of students in the control school tended to decline after intervention compared with those before intervention. This may be related to the timing of the two surveys. The baseline survey was conducted in May when the weather was becoming warmer, whereas the endline survey was conducted in October when it was cooler. Different feelings about the weather may influence the attitude and practice for heat waves, which could induce information bias or memory bias. Even if these kinds of bias can be eliminated using the DID analysis, our results implied that the impacts of the time when questionnaire surveys on climate change-related perception estimation were performed should be considered, particularly for children who usually typically only remember short-term feelings.Several limitations should be noted. First, the general information of participants in the intervention and controls school were not totally balanced and we only adjusted several observed factors, including age, sex, education, and marital status, in the DID analysis. Other possible factors should be further considered in future studies. Second, the pre- and post-intervention surveys were conducted during different seasons, which may induce information bias or memory bias. Third, in the study design, we did not group intervention measures according to the health education activities, so it is difficult to analyze the effects of different activities.The effectiveness of a primary school-based intervention study in China was assessed using difference-in-difference (DID) analysis, with controls for age, sex, etc. The results demonstrated that not only the primary school students but also their parents’ cognition of extreme heat and health adaptation were significantly improved after health education and health promotion were implemented in the intervention school. The KAP improvement of boys and older students was higher than that of girls and younger students. For parents, the higher the education level, the higher the KAP improvement, and the increase was higher for females than for males. Health education in primary school, and particularly education that can influence students’ subjective activeness, was found to be an effective means to improve the cognition and behavior to adapt to heat waves and climate change for both primary school students and their parents. The results indicated that intervention to adapt to climate change should start from an early age in children, and particularly the measures for transferring knowledge to behavior change, and improving pupils’ behaviors or helping them develop good habits. Our findings provide strong evidence for the feasibility and importance of the inclusion of climate change and health in the primary school curricula. Moreover, our findings demonstrated that “small hands holding big hands” is an effective way to improve the awareness and behavior of children and their families to adapt to heat waves, and it has profound significance for enhancing the national capacity to adapt to climate change. The successful experience of our study can be generalized to respond to the increasing extreme weather/climate events in the context of climate change, such as heatwaves, and other emergent occasions or public health education, such as the control and prevention of COVID-19.


As the Internet of Healthcare Things (IoHT) concept emerges today, Wireless Body Area Networks (WBAN) constitute one of the most prominent technologies for improving healthcare services. WBANs are made up of tiny devices that can effectively enhance patient quality of life by collecting and monitoring physiological data and sending it to healthcare givers to assess the criticality of a patient and act accordingly. The collected data must be reliable and correct, and represent the real context to facilitate right and prompt decisions by healthcare personnel. Anomaly detection becomes a field of interest to ensure the reliability of collected data by detecting malicious data patterns that result due to various reasons such as sensor faults, error readings and possible malicious activities. Various anomaly detection solutions have been proposed for WBAN. However, existing detection approaches, which are mostly based on statistical and machine learning techniques, become ineffective in dealing with big data streams and novel context anomalous patterns in WBAN. Therefore, this paper proposed a model that employs the correlations that exist in the different physiological data attributes with the ability of the hybrid Convolutional Long Short-Term Memory (ConvLSTM) techniques to detect both simple point anomalies as well as contextual anomalies in the big data stream of WBAN. Experimental evaluations revealed that an average of 98% of F1-measure and 99% accuracy were reported by the proposed model on different subjects of the datasets compared to 64% achieved by both CNN and LSTM separately. The accelerated development of the Internet of Things (IoT) has attracted attention from stakeholders all over the world due to the combination of the physical world with the virtual world through the Internet for communication and data sharing. IoT has been defined as an interrelated system of mechanical and digital machines, computing devices and objects that is capable of transmitting data over a network without involving human-to-human or human-to-machine interaction. IoT becomes more prevalent every day in many life aspects such as industrial sectors, financial sectors, and healthcare sectors .In healthcare, IoT has improved the quality of care provided to patients. Indeed, people can lead more comfortable lives as it guarantees their health and safety through continuity monitoring. In addition, it supports a wide range of applications, from implantable medical implants to Wireless Body Area Networks (WBAN). WBAN is composed of tiny devices that are considered the most promising technologies for improving healthcare services. These devices have enabled remote monitoring to enhance the overall quality of care provided to patients in remote areas or medical facilities ,3. Despite the merits, WBANs are vulnerable to external attacks as sensor data are collected from various locations and people. People with malicious intent may compromise the sensors and insert malicious data that constitute anomalous readings, leading to incorrect diagnoses and inappropriate medication for patients and substantial financial losses for any organizations that adapt the healthcare system ,5. AnomaMachine learning and statistical techniques have been used to detect anomalies in systems in the past few years. Various researchers have studied the use of these techniques to detect anomalies in healthcare systems and their findings support their effectiveness as in ,7. Howev(1)Developing a method that can benefit from the spatiotemporal correlation among physiological data and the contextual data to choose the most appropriate anomaly detection strategy under a given condition .(2)Classifying the physiological data based on point anomaly (using the dynamic thresholds) and contextual anomaly .(3)Developing an anomaly detection model based on the ConvLSTM deep learning technique to detect both point and contextual anomalies. The proposed model fits big data requirements and time constraints that are important features of the WBAN.In this light, this paper proposes an anomaly detection model that exploits the correlation that exists in measured attributes of WBAN sensors and uses the hybrid ConvLSTM deep learning technique. This model aims to detect anomalous data in WBAN and consider the requirements of the learning process to identify anomalous behavior and provide a reliable system against sensor faults and anomalous activities with an understanding of the factors that impact patients and healthcare organizations. More specifically, it helps to ensure higher detection accuracy and fewer error rates by exploiting the multivariate spatiotemporal correlation between physiological data in WBAN. The contributions of this paper are summarized as follows:The rest of this paper follows the following structure: Anomaly detection receives more attention in the (IoT) domain, especially for healthcare systems that generate massive data from WBAN. Many anomalies detection models have been proposed for WBAN in the literature based on different mechanisms and are analyzed in the subsequent paragraphs.In , the stuUsing a Markov-based chain model, another study , evaluatIn , the stuIn , an apprIn , the stuIn , the stuIn , researcIn , the stuIn , the autIn , the stuIn , The worIn , the resIn , the autIn , authorsRecently, in , the autIn , the stuBased on the above discussion of the existing works, the following subsections analyze them based on two aspects that are the anomaly-related factors, and the used techniques.(a)Anomaly-Related FactorsMost existing studies focused on detecting point anomalies in sensor readings to predict the next potential sensor value and compare it to the actual reading. Few studies considered the case of contextual anomaly between various sensor readings.The temporal correlations play an important role in anomaly detection as the various attributes of multi-variant data may show varying temporal correlations. In addition, the attributes are characterized by frequent changes in data distributions with time. Spatial correlations imply that the data values at a particular sensor node are related to the data samples of the neighboring sensors nodes. As shown in Some existing studies used static thresholds, which may not be sufficient for some reasons; the threshold value of the physiological data is different from one person to another, and it relies on the factors of the person’s lifestyle, age, and medical condition. Therefore, the static threshold will not efficiently work for health monitoring, due to the slow error rate computation and response time. In addition, it is not able to adapt to the continuous changes in medical environments and it requires much effort since it is a manual process. Hence, using dynamic thresholds will be the optimal choice because they calculate value based on the input data . Consequently, the value will be appropriate and accurate with WBAN data.Looking at (b)TechniquesSensors are used in different healthcare monitoring applications, and the data are growing extremely. Therefore, several techniques have been proposed in the literature to improve the effectiveness of anomaly detection approaches in WBAN such as statistical or machine learning techniques. However, such techniques have certain limitations. For example, the statistical techniques cannot deal with the dynamic nature of WBAN and it serves to choose the appropriate threshold value for evaluation. In addition, the non-parametric statistical method is not suitable for real-time applications due to its computational burden. Many of the current techniques use machine learning algorithms such as decision tree, linear regression, artificial neural network, nearest neighbor and random forest. The use of machine learning may not be the preferred option in a sensitive domain such as healthcare that requires high accuracy and good performance. These algorithms have certain limitations in dealing with complex and big data, slow computation, and expecting new patterns of anomalies.To conclude, existing studies have focused on designing techniques for anomaly detection based on correlation with statistical or machine learning, but these techniques are still insufficient to solve the issues. In this domain, detecting an anomaly in the healthcare system requires more effort to understand the nature and importance of the data attributes. Furthermore, a more accurate model that can deal with complex real scenarios is required. In opposition, deep learning is an excellent candidate for overcoming the constraints of the existing techniques mentioned above. Deep learning techniques are capable of learning the inherent data characteristics that distinguish a normal data point from an anomalous one. This approach identifies commonalities in the data and therefore facilitates the detection of anomalies. It is also considered a cost-effective approach for detecting abnormalities because it does not require annotated data for training the algorithms . FurtherThe proposed model involves three phases: Data collection and preprocessing phase, detection phase, and evaluation phase. The data collection and pre-processing phase are used to collect the data by the different physiological sensors and clean the data before applying the detection model. The detection phase is to distinguish between the normal and anomalous data. This phase is divided into point anomaly detection and contextual anomaly detection. The evaluation phase is to test the performance of the model. Dataset: The dataset used in this paper is Multiple Intelligent Monitoring in Intensive Care (MIMIC-I and II) . The models are trained using a batch size of 30 with a different number of epochs. The dataset was split into training and testing datasets using a ratio of 70:30 for train and test partitions, respectively. In this subsection, the results of point anomaly detection and contextual anomaly detection are provided.The physiological data reading is determined as a point anomaly if the classification value exceeds the dynamic threshold; otherwise, it is normal physiological data. The standard deviation of the MAE acts as a dynamic threshold based on the studies in ,42. FiguTo evaluate the ability of the proposed model to detect point anomalies at every data point in the datasets, the loss rate metric is selected because the datasets are not labeled. In It can be concluded that the number of iterations plays an important role in decreasing the loss rates. In addition, there is an inverse correlation between the loss and the number of repetitions. With an increase in the number of repetitions, the loss rates decrease. Moreover, it can be concluded that the reason for the appearance of the spikes is the nature of the data itself such that the sensors containing more anomalies have more spikes. Thus, the performance of the model was as expected because the structure of ConvLSTM is designed to handle point anomalies issues.To investigate the contextual anomaly detection results, we need to clarify the correlation principle that plays a great role here. Two types of correlations are temporal correlations that exist between each sensor reading and the spatial correlations that exist among the different sensors.The contextual anomaly detection approach uses the context principle, which depends on the correlations between sensor readings and measures how these sensors related to each other. For example, +1 refers to a complete positive correlation and +0.8 refers to a strong positive correlation. Similarly, +0.6 refers to moderate positive correlation, whereas 0 means no correlation. When the values go below zero, it means that a negative correlation exists. For example, −0.6 refers to moderate negative correlation and so on. Contextual anomaly detection allows distinguishing between physiological anomalies and sensor faults. The output of the point anomaly detector  with different size and correlation ratios . As shown in Similarly, based on the correlation relationships between ABPDias and ABPSys sensors, the performance of the proposed model on the same 4 subjects is reported in Physiological data are important indicators to assess the condition of the entire human body. From this standpoint, considering all correlation relationships (whether strong or poor) is also important. Therefore, the proposed model was also evaluated on several subjects, taking into account all the correlation relationships in the data. The proposed model was able to detect the anomalies based on ConvLSTM with a context anomaly score. In the experiment, to test the efficacy and robustness of the proposed model, the data were collected from 4 different subjects with different data sizes. Clearly shown in Similarly, for Subjects 2 and 3, the proposed model achieved accuracy and the F1-score of 99%, while a recall and precision of 99% and 100% were also reported. Consequently, the model proved that there is an inverse relationship between loss rate and accuracy—when the loss rate has decreased the accuracy is increased. In addition, there is a positive relationship between accuracy, recall, precision, and F1-score—when the accuracy is increased, the recall, precision, and F1-score are also increased. Overall, the proposed model obtained high accuracy and low loss such that it produces few errors on just some amount of data, which is the perfect case. In addition, the model can detect anomalies even in light of big data with the dynamic context changes of WBAN and different dataset sizes and various conditions achieved with fewer time constraints.Comparative experiments have been conducted with the best and the latest candidates of deep learning and machine learning models in the following subsections. The parameters of the deep learning methods used for comparison are presented in For machine learning methods used in the comparison, a multiclass SVM with linear kernel function, a multiple linear regression, a decision tree with gini criterion, and a random forest with a penalty of 12 was used. For all models, the dataset is split into 70:30 for train and test.A.Deep Learning TechniquesThe proposed model in this paper uses a hybrid model that integrates convolutional and LSTM techniques. This section compares the performance of both convolutional and LSTM separately with the proposed model. As shown in B.Machine Learning TechniquesIn the literature, most anomaly detection studies for WBAN utilized various machine learning models. Therefore, the proposed model will be compared with some existing machine learning models such as Linear Regression (LR), Decision Tree classifier (DT), Random Forest classifier (RF), and Support Vector Machine (SVM) The same random seed is used in the model parameters to ensure that the training data are split in the same way and that each algorithm is evaluated in the same way. The SVM uses a kernel to transform the input data into the required form; the kernel has been called the kernel trick. The reason behind selecting these algorithms is that they are used for classification purposes and are suitable for the dataset pattern. To summarize, as shown in IoHT paradigm and WBAN will play a significant role in developing next-generation healthcare applications and services. One primary concern is how to deal with anomalies, as they are imperative in IoHT due to low cost and constrained sensors. Anomalies need to be identified and appropriate action must be taken to maintain the reliability of smart healthcare applications and services. In this paper, the proposed model takes leverage from the ability of LSTM in benefiting from temporal dependencies that exist in sensor readings, and the ability of convolutional neural networks to spatially examine the relationship between more than one sensor. Experiments on the real world dataset for healthcare vital signs called Physionet assure the ability of the proposed model in detecting both point anomalies and contextual anomalies effectively and efficiently. The performance evaluation and comparison with the state-of-art machine and deep learning models showed the superiority of the proposed with an average prediction accuracy of 99% and an F1-score of 98% in 60 s. As a future plan, an investigation of the effect of adversarial attacks on the proposed model will be examined to show the robustness of deep learning techniques against such attacks.


The Great War (1914–1918) caused a dramatic increase in the number of limbless invalids. Orthopaedics became the field of medicine that could offer the most effective help for those patients.This review article aims to present how new operations and methods in the field of orthopaedics spread to other countries during the Great War.Historical photographs of patients treated by being given hand prostheses are analysed and discussed as a case study of the transfer of orthopaedic techniques in Europe. The pictures were taken in a provincial military hospital, directed by Ireneusz Wierzejewski, the pioneer of orthopaedics in Poland.The methods of preparing stumps for prostheses at Wierzejewski’s hospital followed the patterns of the time. In some cases, the prostheses were further modified to better help patients return to their former lives.The case of the Fortress Hospital in Poznań demonstrates that kinetic hand prostheses were also available in provincial hospitals. Modern orthopaedic procedures remain an effective treatment and a way to restore amputees to society. Orthopaedics emerged as a branch of surgery at the turn of the twentieth century, the First World War (1914–1918), also referred to as the Great War, soon providing indisputable arguments for its development as hundreds of thousands of people needed functional hand prostheses. However, mechanical hands had not yet been designed and produced on a large scale. For the governments involved in the war, the challenge became a stimulus to focus on orthopaedics as a speciality of exceptional social and economic importance.Over centuries, the disabled had been stigmatized as a social burden. In 1908, Konrad Biesalski (1868–1930), a German surgeon, perceived “a cripple as a sick person” who needs surgery and treatment. Nevertheless, in 1914–1918, limbless soldiers needed more than treatment. Their moral right was to return to the kind of life they had led before the war. Only orthopaedists could make that possible. From 1915, when the war planned by the Germans to be over quickly turned into trench warfare, the loss of the ability to fight became a central problem for the German Army. Patriotic German surgeons were involved in the design of an ideal mechanical hand. However, before the mass industrial production of artificial hands was launched, ad hoc solutions were needed locally. Far from the Western Front, surgeons in small hospitals used their experience in orthopaedics to provide amputees with prostheses patterned on the Sauerbruch arm (more on this later) or other types of original hand prosthesis produced by artisans. One of these surgeons was Ireneusz Wierzejewski (1867–1930), the pioneer of orthopaedics in Poland.A collection of 58 photographs from 1915 to 1918, kept by Wierzejewski’s granddaughter and unpublished until now, documented his achievements in prosthetics. The photographs were taken to demonstrate the humanitarian, economic, and military dimensions of orthopaedics. They popularized the kinematic procedure and its usefulness for injured soldiers who, by virtue of functional prostheses, regained their well-being and ability to work. This article aims to analyse the content of these photographs to investigate how new orthopaedic procedures and methods spread in Europe during the Great War [The beginnings of upper-limb prosthetics go back to antiquity; however, the idea of a voluntarily moved mechanical hand was developed in sixteenth-century Nuremberg . The proThe theory behind cineplastic operations, introduced in 1898 by Giuliano Vanghetti 1861–1940), an Italian physician acquainted with neuroplasticity theory and other achievements of physiology, became a milestone in the development of prosthetics. Touched by the tragedy of Italian soldiers mutilated by the Abyssinians, Vanghetti wrote a series of articles on his concept of a hand prosthesis powered by the remaining muscles of the stump and stimulated directly from the brain. According to him, under the influence of physical exercises, a newly formed muscle element reaches its innervation by the mechanism of peripheral neural plasticity. Vanghetti suggested that a surgeon should be able to select tendons and muscles based on their force and function and suture them to form a tendonous-muscular loop enveloped by skin flaps. A padded ring could then be put around the stump above the radius and ulna. The flexors and extensors pulling the stump upwards would give power to the prosthesis, and the patient would be able to voluntarily bend the fingers of the mechanical hand using cords linked to this ring . Not bei1–1940, aThe demand for prostheses grew substantially during the Great War, as mines, dum-dum missiles, and grenades devastated the human resources of all armies. The number of limbless soldiers increased to unprecedented levels, and their return to the Front depended on functional mechanical hands, which had not yet been invented. In 1915, independently of Vanghetti, Ferdinand Sauerbruch 1875–1951) described an innovative operation in which the residual muscles of the stump were stitched to form a loop with a pedunculated flap of skin to be drawn through the tunnel of the muscle [5–1951 deIn a military hospital in Singen, Germany, Sauerbruch improved skin tunnel formation in the proximal part of the stump to increase the productivity of the remaining muscles. Many surgeons tried to perform this operation, but the results were poor because they were not acquainted with plastic surgery techniques. Thus, the German Ministry of War recommended that Sauerbruch’s cineplastic operation be done only by surgeons trained in Singen. Sauerbruch obtained exclusivity in the training of kinematic operations in Germany. Working out the cineplastic procedure was not easy, but starting anew technology involving a voluntarily moved prosthesis was much more complicated and expensive. It was only in 1918, with the support of Badischer Heimatdankes from Karlsruhe and the arms manufacturer Alfons Mauser from Cologne, that Sauerbruch was able to establish a workshop in Singen. In the following year, a new distribution system for standardized upper-limb prostheses and their components was created throughout Germany. Nonetheless, Sauerbruch’s achievements soon failed because inflammation and infection were frequent in the tunnel of the stump. At the end of 1918, the procedure was modified by Max Lebsche (1886–1957), who worked closely with Sauerbruch .Germany demonstrated a pragmatic attitude towards limbless veterans. From 1915, a prosthesis testing centre produced interchangeable parts for prostheses for fourteen different professions. In the early stages of the Great War, the Germans accepted the American Carnes artificial arm with a tie-rod. However, when, in 1917, the US Forces entered the theatre of war, the import of this prosthesis was suspended. German orthopaedists stressed that mechanical hands for German soldiers should be manufactured only in Germany. Otherwise, German soldiers injured by American grenades would be provided with American prostheses.Patients who lost both arms were not given two Sauerbruch prostheses, but an attempt was made to form Krukenberg plastics on the stump. Hermann Krukenberg (1863–1935) invented an amputation procedure in which the stump is a prosthesis. He transformed the forearm stump into a pincer with two branches covered with skin and retaining the sense of touch. After training, a pincer could work as a hand. The Krukenberg operation was also recommended for the blind . In deveJakob Hüfner (1874–1968) ends this list of inventors of upper-limb prostheses at the time of the Great War. He developed a mechanical hand that could be actively opened and closed . The demDuring the Great War, the production of artificial hands in Germany was insufficient and their shortage was severe in peripheral hospitals. One of these was the 13th Fortress Hospital in Poznan , which was operating in 1915–1918. It had been opened in 1913 as an orthopaedic hospital for children and was organized and managed by Ireneusz Wierzejewski.Born to a forest inspector’s family near Poznan, Wierzejewski was too poor to study at university. After graduating from high school, he took a job in an iron tools and agricultural machines factory. Working successively as a locksmith, turner, founder, and blacksmith, he acquired the skills necessary to design and construct prostheses. By 1903, Wierzejewski had saved enough money to start medical studies at the university in Greifswald, and then in Berlin, Wurzburg, and Munich, where, in 1908, he received a diploma. He took an assistant position in the Munich Clinic of Surgery and Orthopaedics, headed by Fritz Lange, who greatly appreciated Wierzejewski’s predisposition to orthopaedics. Lange could not, however, hire him fulltime, so he recommended the young physician to Konrad Biesalski, the founder and director of the newly created Berlin-Brandenburg Therapeutic and Educational Institution for the Crippled . Biesalski was the first to perceive someone with a disability as a sick person to be treated. In his institution, children with scoliosis and other deformities and disabilities were treated with orthopaedic appliances; others, with congenital defects and bone tuberculosis, were operated on and provided with prostheses manufactured in nearby orthopaedic workshops. Under Biesalski , WierzejIn 1910, Wierzejewski obtained a doctorate in Leipzig. In the following year, he returned to Poznan to organize the first Polish orthopaedic hospital for children with acquired disabilities. In 1913, the hospital was opened with 36 beds. Wierzejewski took the position as its director and chief physician. He also organized orthopaedic workshops .In 1915, the Germans transformed the Poznan orthopaedic hospital into the 13th Fortress Hospital. Conscripted into the German Army, Wierzejewski became its orthopaedics consultant and the hospital commander. Until the end of the war, he performed surgeries and treated around 8000 wounded soldiers, primarily privates of Polish origin. Most of them needed artificial hands to return to the Army or, in line with German regulations at the time, take a job in agriculture or industry .When Poland regained independence in 1918, Wierzejewski organized the Polish sanitary troops and commanded them, fighting Germany to stabilize the western state borders. Then the Fortress Hospital was closed. In 1921, the orthopaedic hospital for children was reopened and became the site of the first orthopaedic clinic in Poland, run by Wierzejewski as an associate professor. His research interests then focused on the surgical and other treatment of scoliosis, hummock, and clubfoot. In 1928, he founded the Polish Orthopaedic Society. In 1930, he died from injuries sustained in a car accident. His orthopaedic activity in the wartime was the combination of theories regarding artificial hands, knowledge of neurology, and his many surgical and other technical skills .Most of the patients admitted to the 13th Fortress Hospital suffered from combat injuries and bullet wounds that had damaged the peripheral nerves. They were treated with surgery, helped to regain their strength by performing gymnastics, and finally provided with prostheses if they were needed . The hosSome photographs suggest that Wierzejewski also performed Vanghetti’s plastics on stumps. It is possible that some limbless veterans lost their hands directly on the battlefield and Wierzejewski only provided prostheses manufactured in the nearby workshops for them Fig. .Fig. 3A Trained practically in metalworking and mechanics, and acquainted with advances in neurology and surgery, Wierzejewski was an ingenious designer of inexpensive and functional artificial hands. His prostheses resembled neither the Carnes arm nor the Sauerbruch hand, even with Lebsche’s modifications. Wierzejewski did not use a harness or straps to fix a mechanical hand. His prostheses were directly connected to the loop at the end of the stump and made of the materials available. The prostheses also had interchangeable tips, such as a hammer, pincers, or gripper, making labour in a factory, or craft workshop possible. They had a disadvantage, however, because they substituted the lost limb to a limited extent, enabling only such manual activities as grabbing and dropping objects, sweeping, or metalworking Fig. .Fig. 4PrThe hook prosthesis was cheaper but also useful. The leather sleeve camouflaged the hook and other metal parts of the prosthesis to fulfil cosmetic standards, as in the Sauerbruch arm Fig. .Fig. 5PrWierzejewski could also improve partially fingerless hands. Skilled in the transplantation of tendon and bone, he relocated one of the patient’s toes or thumbs to restore the ability of the palm to grasp. He masked the stumps of the fingers with a leather cover or a glove.The idea of using residual stump muscles to operate an artificial prosthetic hand became technically achievable and possible to implement in surgical practice at the beginning of the twentieth century. Wierzejewski’s professional activities demonstrated that even orthopaedists from provincial hospitals at that time had a wide range of opportunities to offer this modern assistance to their patients. His achievements in prosthetics fit with the history of the Great War. He provided artificial hands constructed using the patterns of Sauerbruch’s, Lebsche’s, and Vanghetti’s prostheses. The photographs taken in Wierzejewski’s hospital and now presented above for the first time to the public also demonstrate another significant phenomenon: the potential of orthopaedics to change human minds. Bringing amputees back to society was not only a medical issue. It also needed a sensitive and empathic society. Since the very beginning of orthopaedics, its philosophical frames and mission were to give people with disabilities a better life and a dignified place in society and to restore, at least in part, lost, or disordered function of the musculoskeletal system. The photographs also demonstrate that orthopaedic technologies could change the course of history, in global and undoubtedly individual terms. Such artificial aids influenced the lives of badly injured patients invaluably—men of working-age. They restored hope to people from the marginalized fringes of society: they allowed those men to perform simple tasks, improved the self-service capacity in everyday life, and masked the frustrating stigma of disability. Kinetic hand prostheses also had a propaganda overtone, reducing the fear of recruits of a different nationality serving in the German Army. Furthermore, Wierzejewski’s inventions were a kind of business card for him, presenting his versatile talents.


The COVID-19 pandemic has posed and is continuously posing enormous societal and health challenges worldwide. The research community has mobilized to develop novel projects to find a cure or a vaccine, as well as to contribute to mass testing, which has been a critical measure to contain the infection in several countries. Through this article, we share our experiences and learnings as a group of volunteers at the Centre for Genomic Regulation (CRG) in Barcelona, Spain. As members of the ORFEU project, an initiative by the Government of Catalonia to achieve mass testing of people at risk and contain the epidemic in Spain, we share our motivations, challenges and the key lessons learnt, which we feel will help better prepare the global society to address similar situations in the future. The recent turn of events worldwide, brought on by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that uprooted the world of all normality, presented a tremendous challenge. In tragic unison, COVID-19 became the viper to humanity’s Eurydice, and the world of researchers and medics, her Orpheus, in our attempt to revive and reset. With a name inspired by this mythological allegory, the Catalan government launched the ‘ORFEU’ project – a mass testing initiative to identify infected individuals – in an attempt to reduce infection rates and facilitate an easier transition into a post-confinement era. At the time that the government decided to launch the ORFEU project, the epidemic in Catalonia was at a critical high. In April 2020, the infection rates and mortality were peaking, and the health system was rapidly overwhelmed. As a result, no systematic testing initiatives were in place in various critical settings such as nursing homes, prisons or clinical institutions due to the vast demand for tests for symptomatic people in hospitals.With the aim of performing 170,000 PCR-based COVID-19 tests, the ORFEU project united some of the major research institutes across Catalonia. There were two main sample-processing nodes with close to 200 volunteers collectively – one at the Barcelona Biomedical Research Park (PRBB) orchestrated by the Center for Genomic Regulation (CRG) and the other at Barcelona Science Park (PCB), jointly coordinated by IRB Barcelona, IBEC and the CNAG-CRG . Both noExtraordinary times call for extraordinary measures. We saw a need that needed to be filled and we stepped in to help.” - Benet Wilson“The motivations of all the volunteers were diverse. While for some it was curiosity to better understand the on-ground scene, others hoped to get a much-desired alternative to in-house confinement. For others less fortunate, the motivation was fuelled by personal experiences with loved ones having suffered through the infection. But most of all, and unanimously, the underlying motivation was to help society fight against the pandemic by offering our specific skill sets and spreading the knowledge needed to battle the crisis. Together, obstacles such as reduced public transport, commuting distances and the inherent human fear factor, were overcome by our will to curb the pandemic through our contributions in the ORFEU project. and Centre for Disease Control and Prevention were established. In addition, a Biosafety Level 2 facility was modified by introducing level 3 measures, such as exclusive changing rooms and protective equipment disposal protocols, which was pivotal in our ability to deal with SARS-CoV-2 samples due to the need for adequate disinfection and correct storage. In the second phase, given our inexperience in handling such an emergency, adequate training of volunteers was critical. To start, a core team of volunteers of around 10 members were instructed on biosafety measures through an online training session given by an external expert in Biosafety Level 3 followed by a hands-onin situ training in smaller groups. All members were trained equally in sample collection and disinfection, sample registration, RNA extraction, PCR and validation, allowing fail-safes and contingencies in cases when members were not able to carry on for any reason. Eventually more volunteers were recruited based on sample load and divided into specialised groups led by a member from the core team. The entire workflow was monitored using a laboratory information management system (LIMS) developedad hoc by the Bioinformatics Unit at CNAG-CRG and a user interface program for sample registration developed by the CRG bioinformatics unit. Together, the LIMS allowed for the smooth and rapid management of samples in an efficient and errorless process between various teams. Expert clinical microbiologists, from various collaborating hospitals, interpreted the PCR results online in a user-friendly module of the LIMS, and carried out the final task of diagnosis.At the outset, once called into the ORFEU project, the CRG health and safety department achieved the mammoth task of adapting the research centre into an analytical and diagnostic centre. There were two major phases to this. First, a biosafety protocol outlining key information such as SARS-CoV-2 sample collection and handling, based on the procedures from the World Health Organisation.The ultimate aim was to automate the process for speedy sample processing as well as reproducibility using high-throughput TECAN robots (one of which was kindly loaned to the CRG by the company) and multiple RT-PCR machines (one kindly lent by the University Pompeu Fabra). Nevertheless, the importance of manual tasks and supervision was paramount, and required approximately three shifts of 4–5 hours every other day, with approximately 4–5 volunteers per shift. Having started at a few hundred samples processed per day, by the end of the project, the CRG was in a position to process 2500–3000 samples per day, with a turnaround time from sample reception to results in about 24–48 hours . The wor, we identified key steps to assure process standardization and optimisation. Here we highlight some of the major points.To ensure the systematic running of the entire unit, it was important to establish a general workflow based on the process mentioned above. Through our implementation of the setup.A project of this scale requires navigating through a large amount of administrative and legal procedures, as well as coordinating many different organisations and teams. Resolving each of these issues caused an initial delay between the proposed and actual start of the project, resulting in a lower overall turnaround of test results than intended. Moreover, the sporadic receipt of samples from various parts of Catalonia presented a challenge in terms of organising shifts, adequate storage and handling, and quick turnaround time . The CRG now has a go-to model ready for use in future situations to share with other organizationsOne of the main challenges during the project was the simultaneous development of an online informatics platform, whilst the laboratory workflow was being designed. Our aim was to develop a platform that enabled tracking of all samples throughout the process internally and also provided an interactive and user-friendly analysis environment for third-party use by collaborating microbiologists to interpret the results. To achieve this, the CNAG-CRG, together with CRG bioinformaticians, developed a LIMS that included a diagnosis validation tool. The PCR testing protocol had two major aspects – RNA extraction and real-time quantitative PCR. Identifying the optimal combination of reagents with sample processing equipment was arguably the most challenging part and is a must to be tackled at the earliest. The initial phase was subject to continual switching between different RNA extraction kits and equipment, which called for exhaustively long working hours and time-consuming daily training.Communication and transfer of knowledge posed major challenges as well. Using dedicated social media channels and live cloud-based services helped in sharing status updates between shifts and quick responses to unexpected technical issues.A continuous logistical challenge throughout the course of the project was the limited availability of reagents and materials. In order to circumvent this issue, reduce the pressure on manufacturing units and optimise overall project costs, the CRG organised a protein production team that performed expression and purification of all the necessary proteins as a backup in the event that the supply chain broke completely. Protocols were initially tested on a small scale by the CRG’s Protein Technologies Unit and further expanded by volunteers. Moreover, extensive further validation and certification of these proteins in PCR mixes or as other reagents are limiting steps prior to them being available for analytical use.Often taken for granted, one of the main challenges during the coordination of a crisis initiative such as the ORFEU project was taking into account personal and professional lives. On one hand, at a personal level, the stress of the lockdown and having children at home or living with high-risk individuals made it difficult to volunteer. Accommodating for lockdown-induced anxiety and mental health needs was very important. On the other hand, from a professional point of view, the delays and late start of the project, which coincided with the reopening of many labs, made it difficult to balance between the two. In addition, and very importantly, as basic researchers, we needed to accept a new responsibility, that results from this project would directly impact people’s lives.The outcomes we achieved in the ORFEU project would not have been possible without some key aspects that contributed to its success.Above all, the motivation, commitment and effort of everyone involved, working towards a common objective, was a very strong driving force that kept us on track, despite the obstacles. The trust of the administration in the volunteers allowed us to take the lead on various aspects of the project, enabling productivity and creating an atmosphere of trust and motivation.Teamwork and cooperation were, as always, critical. Working together in a friendly, supportive and cooperative environment made it easier to cope with stress and difficult situations without unnecessary conflict. The level of mutual respect was very high and communication was transparent, preventing any tension within the team despite varying opinions, changing protocols and long working hours.While the entire team’s effort was very important, it is necessary to highlight that without the dedication and perseverance of the initial organising team, and the various principal investigators, the project would not have been possible. Their tireless commitment for the optimisation of protocols and round-the-clock availability were indispensable stepping-stones for the rest of the team to be able to deliver on the project targets.A major turning point in our ability to handle large volumes of samples came through the tireless efforts of highly skilled personnel at the CRG core facilities who worked to overcome technical hurdles and managed, for instance, to convert a robot that was processing 96 samples every 90 min to processing 384 samples in the same time.Delegation of tasks and specialised teams became a critical factor in speeding up not only the sample-processing rate but also the training and induction of different groups of volunteers. Given the clear communication and coordination between specialised teams, typically overseen by rotating team leaders, the whole process adopted a very smooth and high-throughput functioning capacity.Converting a research centre into an analytical platform is not easy: Despite the resources and technical expertise, setting-up an analytical platform from scratch and under a state of emergency was a complex process. Added to the challenges intrinsic to the novel social responsibilities, and the professional responsibility of delivering accurate results, the preparation of this platform required various obstacles to be negotiated.Create a collaborative work environment: A strong team built through collaboration between researchers, the government and health professionals, with a varied skill set and good morale proved to be essential. Stratified decision-making, accountability, and distribution of tasks can promote the efficient functioning of the unit. Moreover, cross-institute collaborations, which arise from such projects, are long-term connections that can present opportunities for collaboration on various projects across disciplines and sectors, for instance between basic researchers, clinicians, health authorities and policymakers.Technical assurance is critical: The transition from the creation of LIMS to its usability was an important process requiring optimization and often limiting sample processing rates. During the user interface design, it was critical to avoid making assumptions. The entire development process benefited from monitoring usage of the tool after an initial training session, as well as through the course of the project. Documenting workflows and database schemas was fundamental. Additionally, prioritization and differentiation between critical and non-critical features allowed the optimal use of limited software development personnel.Importance of good communication: Communication is one of the cornerstones of an efficient system. Establishing communication channels quickly through social media, live cloud-based services or internal institute-based communication systems available to everyone involved was very important to guarantee an effective workflow, and to ensure transparency, robustness and stability.Protocol standardization: The initial stages of the ORFEU project witnessed a lot of changing protocols and volunteers were required to adapt very quickly. Multiple tests were needed to optimize both processes, and as mentioned above technical developments were needed to increase the capacity of the RNA extraction robots. Although not discussed here, we found numerous artefacts in the PCR reactions. For instance, something as banal as minor traces of ethanol in the reaction could induce artifactual amplification, or the contamination of neighbouring wells in plates where a patient had a very large viral load. SeeOpen access and availability of organizational workflow and protocols: All protocols, as well as optimization trials (including negative results), from situations such as the COVID-19 pandemic, would gain from being shared openly by enabling other research centres and institutions to make better use of their resources. Moreover, these are important opportunities to initiate dialogue and collaboration between local and global research institutions, alongside local governments and health authorities. This would allow them to put in place emergency plans and workflows that can prevent loss of precious time and scarce resources, as was exemplified in the initial phases of the ORFEU project.Researchers and research are important to society: Beyond knowledge creation, researchers can mobilize quickly to produce tangible outcomes for the benefit of society. Proven across Catalonia, and globally, researchers can respond and adapt rapidly and effectively to emergencies, collaborating with local healthcare systems. As a result, a greater consideration for scientific research from governments, health authorities and society would better leverage resources during a health crisis.1. A general but adaptable workflow should initially be established by a core team of administrators, researchers and informaticians. Additional teams should closely follow to prevent exhaustion of the leading team and sustain productivity. To ensure readiness, an emergency response team should revisit the entire workflow annually and adapt it to address any potential issues based on current infrastructure, availability of personnel, and other possible complications.2. Define clear tasks and responsibilities as soon as possible. The combination of specialized teams and a small group of people with broader knowledge ensures efficiency and robustness.3. An initial database schema should be agreed upon ahead of time followed by suitable data transfer formats and protocols between systems . To ensure the systematic transfer of samples and eventually results, set up a common platform with the health authorities to assure transparent communication of all necessary logistic information.4. Set up dedicated communication channels that allow fast information transfer and updates.5. Volunteers should be recurrently tested, and not exclusively at the start of the programme. This will ensure mental peace and health safety of all directly or indirectly involved, as a result, ensuring sustainability of the project.6. Set up a pipeline to produce your own reagents (RT-PCR master mix and RNA extraction kits), so as not to solely rely on external sources to acquire them.7. Open access protocols should be shared across research centres and health institutions as soon as they are standardised. Problems arising during their development should also be communicated to avoid needless repetition.8. Equipment and pipelines should not be dismantled until normality has been reinstated globally to prepare for future outbreaks and the possible need for testing protocols.9. volunteer recruitment process should continue as a backup for as long as possible.In emergencies, requirements are dynamic and processes can change very quickly. Hence, the10. Understanding from supervisors and recognition from funding agencies and government bodies, for instance by extending fellowships, would attract more support.Despite being volunteer work, all participants worked at their own projects’ expense.No data are associated with this article. et al., in this opinion article, highlight the success behind the mammoth responsibility which was imposed upon the Catalan government and the role played by volunteers and researchers of the ORFEU project.Ghose The authors have highlighted the key challenges faced and the lessons learned while successfully implementing this mammoth task. To overcome similar challenges that can arise in the future, authors have given a ten-point recommendation to be prepared for the subsequent pandemics.Is the topic of the opinion article discussed accurately in the context of the current literature?YesAre arguments sufficiently supported by evidence from the published literature?YesAre all factual statements correct and adequately supported by citations?YesAre the conclusions drawn balanced and justified on the basis of the presented arguments?YesReviewer Expertise:Immunology, GenomicsI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This opinion article is truly an example on how scientists have assisted society during COVID-19 pandemic, by adapting and perform wide-scale testing in their communities. Scientists have a set of skills and knowledge of protocols, techniques and methodology, and these resources are sometimes ignored and left out by health authorities. That was not the case of Catalan government decided to launch ORFEU program, to avail the existing expertise and test capability and scale it up with the help of many volunteers that mobilize to perform a massive effort of COVID-19 testing. This article documents the insight vision, point of view, motivation and challenges of the volunteers from PRBB during this process. Besides the success stories, the learned lessons and perspectives from this transition and this period are very important and they can be explored in less troubled times. It is important to pinpoint some of these lessons such as: balancing mental health and anxiety with new responsibilities; creating a collaborative work environment based on trust and cross institutes collaborations; good communication and mechanisms for sharing open data  and the effort on standardization and automatization of protocols. Although not fully discussed, the protocols and guidelines are referenced along the text and are available for consultation. The ten recommendations are clear and solid and undoubtedly resulting from an intensive planification effort and posterior discussion and it can be directly transferred to other institutes, to be consider in new upcoming events and future outbreaks.Is the topic of the opinion article discussed accurately in the context of the current literature?YesAre arguments sufficiently supported by evidence from the published literature?YesAre all factual statements correct and adequately supported by citations?YesAre the conclusions drawn balanced and justified on the basis of the presented arguments?YesReviewer Expertise:Genomics, sequencing, single cell, bioinformatics.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.